Principles and Practice of
Geriatric Psychiatry Third Edition
Edited by
Mohammed T. Abou-Saleh St George’s Hospital Medical School, London, UK
Cornelius Katona University College London, London, UK
Anand Kumar University of Illinois, Illinois, USA
A John Wiley and Sons, Ltd., Publication
Principles and Practice of
Geriatric Psychiatry
Principles and Practice of
Geriatric Psychiatry Third Edition
Edited by
Mohammed T. Abou-Saleh St George’s Hospital Medical School, London, UK
Cornelius Katona University College London, London, UK
Anand Kumar University of Illinois, Illinois, USA
A John Wiley and Sons, Ltd., Publication
This edition first published 2011 2011 by John Wiley & Sons, Ltd. Wiley-Blackwell is an imprint of John Wiley & Sons, formed by the merger of Wiley’s global Scientific, Technical and Medical business with Blackwell Publishing. Registered office: John Wiley & Sons, Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK Editorial offices:
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First Impression 2011
Dedication
Dedicated to our wives and families
Associate Editors
Dave Anderson Mersey Care NHS Trust Older People’s Mental Health Services Sir Douglas Crawford Unit, Mossley Hill Hospital Park Avenue Liverpool L18 8BU, UK
Chris Fox Folkestone Health Centre 15-25 Dover Road Folkestone Kent CT20 1JY, UK
Mary Ganguli Western Psychiatric Institute and Clinic 3811 O’Hara St. Pittsburgh, PA 15213, USA
Constantine G. Lyketsos The Johns Hopkins Bayview Medical Center 5300 Alpha Commons Drive Alpha Commons Building, 4th Floor Baltimore, MD 21224, USA
Zuzana Walker Department of Mental Health Sciences St Margaret’s Hospital Epping Essex, CM16 6TN UK
Kenneth Wilson St Catherine’s Hospital Church Road Birkenhead Wirral L42 OLQ, UK
Contents
Contributors xiii Preface xxi Preface to Second Edition xxii Preface to First Edition xxiii
PART A 1 2 3
A Conceptual History in the Nineteenth Century 3 German E. Berrios The Development of Old Age Psychiatry in the UK 7 Claire Hilton and Tom Arie Commentary on ‘In the Beginning’ by Felix Post 12 Claire Hilton
PART B 4
5 6 7 8 9 10 11 12 13 14
HISTORICAL BACKGROUND 1
NORMAL AND ABNORMAL AGEING 15
Changes in the Macrostructure and Microstructure of the Ageing Brain 17 Natalie M. Zahr, Adolf Pfefferbaum and Edith V. Sullivan Functional Imaging of the Ageing Brain 28 Robert Perneczky, Christian Sorg and Hans F¨orstl Neurophysiology of the Ageing Brain 36 Paolo Maria Rossini and Laura Parisi Potential Regeneration of the Ageing Brain 42 Stephen B. Dunnett Neuroendocrinology of Ageing 45 Marcus Simmgen Genetic Aspects of Ageing 51 Ben Pickard and Douglas Blackwood The Clinical Pharmacology of Ageing 55 Brian Clarke and S. H. D. Jackson Cognitive Gerontology 60 Patrick Rabbitt Chronological and Functional Ageing 65 David Melzer and Iain Lang Successful Ageing 70 Ann Bowling Sexuality, Non-Traditional Relationships and Mental Health in Older People 74 Ian Peate
15 The Care Home Experience 78 Alisoun Milne 16 Ageing: International Statistical Trends and Prospects 83 Fiona E. Matthews and George M. Savva 17 Economics of Ageing and Mental Health 90 Anders Wimo 18 The Influence of Social Factors on Mental Health 97 Donna D. McAlpine and David Mechanic
PART C DIAGNOSIS AND ASSESSMENT 103 19 Classification of Dementia and other Cognitive Disorders in ICD-10 and DSM-IV 105 A. Jablensky and J.E. Cooper 20 Taking a Psychiatric History from Elderly Patients 109 Sunita Sahu and Monica Crugel 21 Mental State Examination in the Elderly 113 Joanne Rodda and Zuzana Walker 22 The Physical Examination: A Guide for Old Age Psychiatrists 117 Stephen Todd, John O’Hare, Bernadette McGuinness and A. Peter Passmore 23 Investigations in Old Age Psychiatry 122 Sujatha Merve and Robert C. Baldwin 24 Bedside Assessment of Cognitive Functioning 129 Richard Perry 25 Neuropsychological Assessment 135 Linda Clare 26 Overview of Rating Scales in Old Age Psychiatry 141 Kenneth C. M. Wilson, Ben Green and Pat Mottram 27 The Mini-Mental State Examination: A Brief Cognitive Assessment 145 Marshal Folstein, Susan Folstein and Jonathan Folstein 28 The Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) 147 Nicolas Cherbuin and Anthony Francis Jorm 29 Geriatric Depression Scale 152 Meghan A. Marty, Renee Pepin, Andrea June and Daniel L. Segal 30 Dementia Care Mapping 157 Dawn Brooker
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CONTENTS
31 Staging Dementia 162 Barry Reisberg, Imran A. Jamil, Sharjeel Khan, Isabel Monteiro, Carol Torossian, Steven Ferris, Marwan Sabbagh, Serge Gauthier, Stefanie Auer, Melanie B. Shulman, Alan Kluger, Emile Franssen and Jerzy Wegiel 32 The Clinical Dementia Rating 170 Rawan Tarawneh, B. Joy Snider, Mary Coats and John C. Morris 33 GMS-HAS-AGECAT Package and the Global Mental Health Assessment Tool (GMHAT): Epidemiology and Closing the Treatment Gap 174 John R. M. Copeland 34 Assessing Life Skills 176 Colin Depp, Veronica Cardenas, Ashley Cain and Thomas L. Patterson 35 Quality of Life Measures in Old Age 183 Juanita Hoe, Martin Orrell and Gill Livingston
47 Alzheimer’s Disease: Risk Factors and Preventive Strategies 271 JoAnn T. Tschanz and John C. S. Breitner 48 Down Syndrome: Genetic and Clinical Overlap with Dementia 281 Giles M.Y. Tan and Declan G.M. Murphy 49 The Molecular Neuropathology of Alzheimer’s Disease 287 Orly Lazarov 50 Neurochemistry of Alzheimer’s Disease Paul T. Francis
295
51 Antemortem Markers 299 Susan J. van Rensburg, Felix C.V. Potocnik, Maritha J. Kotze and Dan J. Stein 52 Pharmacological Therapies in Alzheimer’s Disease 304 Martin Steinberg and Constantine G. Lyketsos 53 Behavioural Management in Alzheimer’s Disease – Pharmacology 312 David A. Merrill and David L. Sultzer
PART D
DEGENERATIVE AND RELATED
DISORDERS 193 36 Delirium 195 Barbara Kamholz 37 The Nosology of Dementia 201 Kenneth Rockwood 38 Epidemiology of Dementia 207 Mary Ganguli 39 An Introduction to the Medical Research Council Cognitive Function and Ageing Studies (CFAS) I and II 213 Fiona E. Matthews and Carol Brayne 40 The Lundby Study 222 Mats Bogren, Cecilia Mattisson and Per Nettelbladt 41 Clinical Features of Alzheimer’s Disease: Cognitive and Non-cognitive 226 Oludamilola Salami and Constantine G. Lyketsos 42 Neuropsychological Assessment of Dementia and Alzheimer’s Disease 232 David Aaron Maroof and Cynthia A. Munro 43 Genetics of Alzheimer’s Disease 238 Lynn M. Bekris, Chang-En Yu, Thomas D. Bird and Debby Tsuang 44 Mouse Models of Alzheimer’s Disease 252 Esther Oh, Constantine Lyketsos and Philip Wong 45 Physiological Neuroimaging in Ageing and Dementia: Metabolic and Molecular Scanning 257 Markus Donix, Susan Y. Bookheimer and Gary W. Small 46 Computational Anatomy in Alzheimer’s Disease 262 Alex D. Leow, Liana G. Apostolova and Paul M. Thompson
54 Behavioural Management: Non-Pharmacological 324 Jiska Cohen-Mansfield 55 Emerging Applications of Gene and Somatic Cell Therapy in Geriatric Neuropsychiatry 330 Eric Wexler 56 Vascular Dementia 342 Ingmar Skoog 57 The Frontotemporal Dementia Syndromes Mario F. Mendez
348
58 The Lewy Body Dementia Spectrum (Alpha Synucleinopathies) 360 J.-P. Taylor and I. G. McKeith 59 Prion Diseases 372 Brian S. Appleby 60 Alcoholic and Other Toxic Dementias Eileen M. Joyce 61 Reversible Dementias Michael Philpot
378
383
62 Cognitive Domains Affected by Conditions of Ageing and the Role of Neuropsychological Testing 389 Heather R. Romero, Scott M. Hayes and Kathleen A. Welsh-Bohmer 63 Memory Training for Older Adults 397 Karen Miller, Linda Ercoli, Jeanne Kim and Gary W. Small 64 Complementary and Alternative Medicine Approaches to Memory Improvement in the Elderly 403 Helen Lavretsky 65 Ethics of Dementia Care 410 Eran Klein and Jason Karlawish 66 Successful Interventions for Family Caregivers 415 L. McKenzie Zeiss, Yookyung Kwon, Renee Marquett and Dolores Gallagher-Thompson
CONTENTS 67 The Role of Alzheimer Societies in the United States 421 Ruth O’Hara and Bevin Powers 68 Psychiatric Manifestations of Nervous System Infections 426 Jeffrey T. Guptill and E. Wayne Massey 69 Magnetic Resonance Imaging and Computed Tomography 433 Howard Aizenstein and Vijay Venkatraman 70 Functional MRI Studies in Ageing and Early Alzheimer’s Disease 437 Ottavio V. Vitolo and Reisa A. Sperling 71 Magnetic Resonance Spectroscopy 446 Olusola Ajilore, Brent Forester, Matthew R. Woodward and Anand Kumar
PART E
87 Psychotherapy of Depression and Dysthymia 543 Philip Wilkinson 88 Acute Management of Late-Life Depression 552 V. Gardner and D.C. Steffens 89 Bereavement 555 Robert J. Kastenbaum 90 Suicidal Behaviour 559 Brian Draper 91 The Assessment of Depressive Syndromes 565 Adriana P. Hermida and William M. McDonald 92 Mania: Epidemiology and Risk Factors 573 Susan W. Lehmann 93 Acute Mania and Bipolar Affective Disorder 576 M. Sajatovic, N. Herrmann and K.I. Shulman
AFFECTIVE DISORDERS 455
72 Nosology and Classification of Mood Disorders 457 Dan Blazer 73 Genetics of Affective Disorders 460 Carolina Aponte Urdaneta and John L. Beyer 74 Environmental Factors, Life Events and Coping Abilities 464 Toni C. Antonucci and James S. Jackson 75 Vascular Disease and Late-Life Depressive Disorder 468 Robert Baldwin 76 Mood Disorders in Parkinson’s Disease 473 John V. Hindle 77 Epidemiology of Depression: Prevalence and Incidence 479 Ruoling Chen and John Copeland 78 Neuroimaging in Geriatric Depression 489 Faith M. Gunning 79 Clinical Features of Depressive Disorders in the Elderly 495 Davangere P. Devanand and Steven P. Roose 80 The Outcome of Late-life Depressive Disorders 502 Aartjan T.F. Beekman, Harm W.J. van Marwijk and Max L. Stek 81 Physical Illness and Depression 508 Mavis Evans 82 Depression After Stroke 515 Peter Knapp and Allan House 83 Cross-Cultural Variation in the Experience of Depression in Older People in the UK 518 Vanessa Lawrence, Joanna Murray, Anthony Klugman and Sube Banerjee 84 Treatment of Late-Life Depression In Community Settings 524 Carolyn Chew-Graham 85 Electroconvulsive Therapy (ECT) 529 David G. Wilkinson 86 Pharmacological Treatment of Depression 537 Mohammed T. Abou-Saleh and Cornelius Katona
PART F SCHIZOPHRENIC DISORDERS AND MOOD-INCONGRUENT PARANOID STATES 589 94 Late-Life Psychotic Disorders: Nosology and Classification 591 Nicole M. Lanouette, Lisa T. Eyler and Dilip V. Jeste 95 Schizophrenic Disorder and Mood-Incongruent Paranoid States: Epidemiology and Course 596 Cynthia D. Fields and Peter V. Rabins 96 Clinical Assessment and Differential Diagnosis 599 David N. Anderson 97 Treatment of Late-Life Psychosis 604 Peter Connelly and Neil Prentice
PART G NEUROSES (ANXIETY DISORDERS) 609 98 Nosology and Classification of Neurotic Disorders 611 David Bienenfeld 99 The Epidemiology of Depression and Anxiety 616 Robert Stewart and James Lindesay 100 Psychopharmacological Treatment of Anxiety 624 John L. Beyer 101 Obsessive-Compulsive Disorder 632 James Lindesay 102 Somatoform Disorders and Unexplained Physical Symptoms 636 Bart Sheehan 103 Other Neurotic Disorders 640 Jerome J. Schulte, C. Michael Hendricks and David Bienenfeld
PART H PERSONALITY DISORDERS 647 104 Personality Disorders: Description, Aetiology, and Epidemiology 649 Victor Molinari and Daniel L. Segal
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CONTENTS
105 Diagnostic and Treatment Issues Regarding Personality Disorder in Older Adults 655 Richard A. Zweig and Dana Scherr Parchi
PART I MENTAL AND BEHAVIOURAL DISORDERS DUE TO PSYCHOACTIVE SUBSTANCES 663 106 Alcohol Abuse and Treatment in the Elderly 665 Helen H. Kyomen and Benjamin Liptzin 107 Epidemiology of Alcohol Problems and Drinking Patterns 671 Celia F. Hybels and Dan G. Blazer 108 Drug Misuse in the Elderly 679 Martin M. Schmidt and Mohammed T. Abou-Saleh
PART J LEARNING AND BEHAVIOURAL STUDIES 687 109 Old Age and Learning Disability 689 Oyepeju Raji and Asim Naeem 110 The Elderly Offender 694 Graeme A. Yorston 111 Sleep and Ageing: Disorders and Management Helen Chiu and Joshua Tsoh 112 Sexual Disorders 706 Walter Pierre Bouman
700
PART K CULTURAL DIFFERENCES, SERVICE PROVISION AND TRAINING IN OLD AGE PSYCHIATRY 711 113 Assessing Mental Health in Different Cultures 713 Rob Butler, Sati Sembhi and Melanie Abas 114 The Cross-Cultural Epidemiology of Mental Illness in Old Age 717 Martin Prince 115 Mental Illness in the Elderly in South Asia 730 Vikram Patel and K. S. Shaji 116 Dementia and Depression in Africa 734 Olusegun Baiyewu 117 Dementia and Depression in China 737 Helen Chiu and Cindy Tam 118 Spirituality and Mental Illness in Old Age 741 Susan Mary Benbow and David Jolley 119 Development of Health and Social Services in the UK from the Twentieth Century Onwards 745 John P. Wattis 120 The Pattern of Psychogeriatric Services 749 John P. Wattis 121 The Multidisciplinary Team and Day Care Provision 753 Martin Orrell and Kunle Ashaye
122 NHS Continuing Care 759 Clive Ballard, Ramilgan Chitramohan, Zunera Khan and Jean Beh 123 Overview of Law, Ethics and Mental Health in Old Age 766 Julian C. Hughes 124 The US System of Geriatric Mental Health Care: Financing and Future Challenges 770 Stephen J. Bartels 125 Geriatric Psychiatric Outpatient Care: The Private Practice Model in the USA 777 Elliott M. Stein and Gary S. Moak 126 The Medical Psychiatry Inpatient Unit 785 Maria I. Lapid and Teresa A. Rummans 127 Psychiatric Services in Long-Term Care 790 Marc E. Agronin, Stephen M. Scheinthal and Ashok J. Bharucha 128 Geriatric Psychiatry Care in the Private Psychiatric Hospital Setting 796 Brent P. Forester, Robert Kohn, Susan Kim and Thomas Idiculla 129 Liaison with Medical and Surgical Teams 803 David N. Anderson 130 Rehabilitation 810 Rob Jones 131 Anaesthetics and Mental State 817 Andrew Moore Severn and David Gwyn Seymour 132 Nutritional State 824 David N. Anderson and Mohammed T. Abou-Saleh 133 Caregiver Support 829 Kathleen C. Buckwalter, Mary Ellen Stolder, Charlene S. Aaron and Catherine Messinger 134 Elder Abuse – Epidemiology, Recognition and Management 835 Alexander M. Thomson and Martin J. Vernon 135 Care of the Dying 838 Adrian Treloar, Monica Crugel and Waleed Fawzi 136 Prevention of Mental Disorders in Late Life 844 Pim Cuijpers, Filip Smit, Barry D. Lebowitz and Aartjan T. F. Beekman 137 The Principles of UK Mental Health Law: A View from the Clinic 850 Julian C. Hughes 138 Training Requirements for Old Age Psychiatrists in the UK 854 Susan Mary Benbow and Aparna Prasanna 139 Training Requirements in North America 857 Paul D. Kirwin and Kirsten M. Wilkins 140 Education in Old Age Psychiatry: Recent and Future Developments 860 Hugo de Waal Subject Index
864
Contributors
Charlene S. Aaron University of Iowa College of Nursing, 101 Nursing Building, 50 Newton Road, Iowa City, IA 52242-1121, USA
Robert Baldwin Manchester Mental Health & Social Care Trust, Edale House, Manchester Royal Infirmary, Manchester M13 9BX, UK
Melanie Abas Institute of Psychiatry, Kings College London, Box P060, De Crespigny Park, London SE5 8AF, UK
Clive Ballard Wolfson Centre for Age Related Diseases, King’s College London, Guy’s Campus, London SE1 1UL, UK
Mohammed T. Abou-Saleh Division of Mental Health, St George’s, University of London, Cranmer Terrace, London SW17 0RE, UK
Sube Banerjee Institute of Psychiatry, King’s College London, 16 De Crespigny Park, London, SE5 8AF, UK
Marc E. Agronin University of Miami Miller School of Medicine, and Medical Director for Mental Health and Clinical Research, Miami Jewish Health Systems, Miami, FL 33137, USA Howard Aizenstein University of Pittsburgh School of Medicine, Pittsburgh, USA
Stephen J. Bartels Department of Psychiatry, Dartmouth Centers for Health and Aging Dartmouth Medical School, Hanover, NH 03755-1404, USA Aartjan T. F. Beekman VU Medical Center and GGZ in Geest, A.J. Ernststraat 887, Amsterdam 1081 HL, and EMGO Institute for Health and Care Research, VU University and VU University Medical Center, Amsterdam, The Netherlands
Olusola Ajilore Department of Psychiatry, University of IllinoisChicago, 5841 S. Maryland Ave, Chicago, IL 60637, USA
Jean Beh King’s College London, London SE1 1UL, UK
David N. Anderson Mersey Care NHS Trust, Older People’s Mental Health Services, Sir Douglas Crawford Unit, Mossley Hill Hospital, Liverpool L18 8BU, UK
Lynn M. Bekris Departments of Medicine, Neurology and Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA 98195, USA
David N. Anderson Mersey Care NHS Trust, Older People’s Mental Health Services, Sir Douglas Crawford Unit, Mossley Hill Hospital, Liverpool L18 8BU, UK
Susan Mary Benbow Centre for Ageing and Mental Health, Staffordshire University, Stafford ST18 0AD, UK
Toni C. Antonucci Institute for Social Research, University of Michigan, 426 Thompson Street, Ann Arbor, MI 48106-1248, USA Carolina Aponte Urdaneta Duke University Medical Center, Room 3059 Yellow Zone, 200 Trent Dr, Durham, NC 27710 2, USA Liana G. Apostolova Department of Neurology, UCLA David Geffen School of Medicine, Los Angeles, CA 90095, USA Brian S. Appleby Division of Geriatric Psychiatry and Neuropsychiatry, The Johns Hopkins Hospital, Baltimore, MD 21287, USA Tom Arie University of Nottingham, Ageing and Disability Research Unit, The Medical School, Queen’s Medical Centre, Nottingham NG7 2UH, UK Kunle Ashaye Hertfordshire Partnership NHS Trust, Mental Health Unit, Lister Hospital, Coreys Mill Lane, Stevenage, Hertfordshire SG1 4AB, UK Stefanie Auer MAS Alzheimerhilfe, Bad Ischl, Austria Olusegun Baiyewu Department of Psychiatry, College of Medicine, University of Ibadan, Nigeria
German E. Berrios Department of Psychiatry, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 0QQ, UK John L. Beyer Duke University Medical Center, Room 3059 Yellow Zone, 200 Trent Dr, Durham, NC 27710 2, USA Ashok J. Bharucha University of Miami Miller School of Medicine, Miami, Florida, 33136 USA David Bienenfeld Department of Psychiatry, Wright State University Boonshoft School of Medicine, Dayton, OH 3640, USA Thomas D. Bird Geriatrics Research Service, Veterans Affairs Puget Sound Health Care System, Seattle, WA 98108, USA Douglas Blackwood Division of Psychiatry, University of Edinburgh, The Royal Edinburgh Hospital, Edinburgh, EH10 5HF, UK Dan G. Blazer Duke University School of Medicine, Duke University Medical Center, Durham, NC 27710, USA Mats Bogren Department of Clinical Sciences, Psychiatry, The Lundby Study, Lund University Hospital, SE-221 85 Lund, Sweden
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CONTRIBUTORS
Susan Y. Bookheimer Center for Cognitive Neurosciences, Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA Walter Pierre Bouman Mental Health Services for Older People, University Hospital, Nottingham NG7 2UH, UK Ann Bowling Department of Primary Care and Population Health, University College London, London WC1E 6BT, UK Carol Brayne – Chapter 48 Department of Public Health & Primary Care, Institute of Public Health, Robinson Way, Cambridge CB2 2SR, UK
Jiska Cohen-Mansfield George Washington University Medical Center and School of Public Health, Washington DC 20037, USA Tel Aviv University Herczeg Institute on Aging and Sackler Faculty of Medicine, Tel-Aviv, Israel Peter Connelly Murray Royal Hospital, Perth PH2 7BH, UK J. E. Cooper Department of Psychiatry and Behavioural Science, Medical Research Foundation Building, Level 3 Rear, 50 Murray Street, Perth, WA 6000, Australia John R. M. Copeland University of Liverpool, Department of Psychiatry, Section of Old Age Psychiatry, St Catherine’s Hospital, Birkenhead, Wirral, CH42 0LQ, UK
John C. S. Breitner GRECC, VA Puget Sound Health Care System, Division of Geriatric Psychiatry, University of Washington School of Medicine, Seattle, WA 98108, USA
Monica Crugel Oxleas NHS Foundation Trust, Memorial Hospital, Shooters Hill, London, SE18 3RZ, UK
Dawn Brooker University of Worcester Association for Dementia Studies, Institute of Health and Society, University of Worcester, Henwick Grove Campus, Worcester WR2 6AJ, UK.
Pim Cuijpers VU University Amsterdam, Van der Boechorststraat 1, Amsterdam 1081 BT, and EMGO Institute for Health and Care Research, VU University and VU University Medical Center, Amsterdam, The Netherlands
Kathleen C. Buckwalter University of Iowa College of Nursing, 101 Nursing Building, 50 Newton Road, Iowa City, IA 522421121, USA
Hugo de Waal East of England Postgraduate School of Psychiatry, Fulbourne, Cambridge CB21 5XB, UK
Rob Butler Suffolk Mental Health Partnership NHS Trust, St Clement’s Hospital, Foxhall Road, Ipswich, Suffolk IP3 8LS, UK Ashley Cain Department of Psychiatry, University of California – San Diego, MC 0680, 9500 Gilman Drive, La Jolla, CA 92093-0680, USA Veronica Cardenas Department of Psychiatry, University of California – San Diego, MC 0680, 9500 Gilman Drive, La Jolla, CA 92093-0680, USA Ruoling Chen Centre for Health and Social Care Improvement, School of Health and Wellbeing, University of Wolverhampton, Wulfruna Street, Wolverhampton, WV1 1LY, UK Nicolas Cherbuin Centre for Mental Health Research, Australian National University, 63 Eggleston Road, Canberra, ACT 0200, Australia Carolyn Chew-Graham Primary Care Research Group, School of Community Based Medicine, University of Manchester, 5th Floor Williamson Building, Oxford Road, Manchester M13 9PL, UK
Colin Depp Department of Psychiatry, University of California – San Diego, MC 0680, 9500 Gilman Drive, La Jolla, CA 920930680, USA Davangere P. Devanand College of Physicians and Surgeons, Columbia University, and Division of Geriatric Psychiatry, New York State Psychiatric Institute, New York, NY 10032, USA Markus Donix Center for Cognitive Neurosciences, Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA Brian Draper School of Psychiatry, University of NSW, Sydney, NSW 2052, Australia Stephen B. Dunnett School of Biosciences, Cardiff University, Museum Avenue Box 911, Cardiff, CF10 3US, UK Linda Ercoli Department of Psychiatry and Biobehavioral Sciences, Geriatric Psychiatry Division, Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine at UCLA, 760 Westwood Plaza, Suite 37-440, Los Angeles, CA 90024, USA
Ramilgan Chitramohan Birmingham and Solihull Mental Health Foundation Trust, Heartlands Hospital, Birmingham B9 5SS, UK
Mavis Evans Elderly Mental Health Directorate, Wirral and West Cheshire Community NHS Trust, Clatter bridge Hospital, Bebington, Wirral L63 4JY, UK
Helen Chiu Department of Psychiatry, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
Lisa T. Eyler University of California, San Diego, 9500 Gilman Drive, # 9151-B, La Jolla, CA 92093, USA
Linda Clare School of Psychology, Bangor University, Bangor, Gwynedd LL57 2AS, UK
Waleed Fawzi Oxleas NHS Foundation Trust, Memorial Hospital, Shooters Hill, London, SE18 3RZ, UK
Brian Clarke Department of Clinical Gerontology, King’s College Hospital, Denmark Hill, London, SE5 9RS, UK
Steven Ferris Aging and Dementia Clinical Research Center, New York University Langone Medical Center, Center of Excellence on Aging, New York, NY 10016, USA
Mary Coats Department of Neurology, Washington University in St Louis, 660 S. Euclid Avenue, CB 8111, St. Louis, MO 63110, USA
Cynthia D. Fields Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA
CONTRIBUTORS Jonathan Folstein Vanderbilt Universit, Nashville, Tennessee, USA Marshal Folstein University of Miami Miller School of Medicine, Nashville, USA Susan Folstein University of Miami Miller School of Medicine, Nashville, USA Brent Forester Harvard Medical School, McLean Hospital, 115 Mill Street, Belmont, MA 02478, USA Hans F¨orstl Klinik und Poliklinik f¨ur Psychiatrie und Psychotherapie, Klinikum rechts der Isar, Technische Universit¨at M¨unchen, Ismaninger Str. 22, 81675 M¨unchen, Germany Chris Fox Folkestone Health Centre, 15-25 Dover Road, Folkestone, Kent CT20 1JY, UK Paul T. Francis King’s College London, Wolfson Centre for AgeRelated Diseases, Guy’s Campus, London SE1 1UL, UK Emile Franssen Aging and Dementia Clinical Research Center, New York University Langone Medical Center, Center of Excellence on Aging, New York, NY 10016, USA D. Gallagher-Thompson Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Road, Stanford, CA 94305-5717, USA Mary Ganguli Western Psychiatric Institute and Clinic, 3811 O’Hara St. Pittsburgh, PA 15213, USA V. Gardner Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC 3950, USA Serge Gauthier McGill Center for Studies in Aging, Douglas Hospital, Montreal, Quebec H4H 1R2, Canada J P Gibbons Department of Psychiatry and Behavioral Sciences, Center for the Study of Aging and Human Development, Duke University Medical Center, Room 3521 Blue Zone Duke Clinics, Box 3003, Durham, NC 27710, USA Ben Green Department of Psychiatry, University of Liverpool 147, UK Faith M. Gunning Institute of Geriatric Psychiatry, Department of Psychiatry, Weill Cornell Medical College, 21 Bloomingdale Road, White Plains, NY 10605, USA Jeffrey T. Guptill Duke University School of Medicine, Duke University Medical Center, Durham, NC 27710, USA David Gwyn Seymour Medicine for the Elderly, University of Aberdeen, Aberdeen, AB24 3EN, UK Scott M. Hayes Joseph and Kathleen Bryan Alzheimer’s Disease Research Center, Department of Psychiatry. Duke University, Durham, NC 27705, USA C. Michael Hendricks Department of Psychiatry, Wright State University, Boonshoft School of Medicine, OH 3640, USA Adriana P. Hermida Fuquay Center for Late Life Depression, Emory University School of Medicine, Atlanta, GA 30329-5120, USA
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N. Herrmann Sunnybrook Health Sciences Centre, Toronto, Ontario, M4N 3M5, Canada Claire Hilton Mental Health Service for Older Adults, Central and North West London NHS Foundation Trust, Bentley House, Harrow HA3 5QX, UK John V. Hindle School of Medical Sciences, University of Bangor, Llandudno Hospital, Llandudno, Conwy, LL30 1LB, UK Juanita Hoe Department of Mental Health Sciences, University College London, London W1W 7EJ, UK Allan House School of Healthcare, University of Leeds, Leeds LS2 9JT, UK Julian C. Hughes Northumbria Healthcare NHS Foundation Trust and Institute for Ageing and Health, Newcastle University, Newcastle Upon Tyne, NE1 7RU UK Celia F. Hybels Department of Psychiatry and Behavioral Sciences, Center for the Study of Aging and Human Development, Duke University Medical Center, Room 1505 Blue Zone Duke Clinics, Box 3003, Durham, NC 27710, USA Thomas Idiculla Mental Health Services Evaluation Dept, McLean Hospital, 115 Mill St, Belmont, MA 02478, USA James S. Jackson Institute for Social Research, University of Michigan, Ann Arbor 48502, USA S. H. D. Jackson Department of Clinical Gerontology, King’s College Hospital, Denmark Hill, London, SE5 9RS, UK A. Jablensky Department of Psychiatry and Behavioural Science, Medical Research Foundation Building, Level 3 Rear, 50 Murray Street, Perth, WA 6000, Australia Imran A. Jamil Aging and Dementia Clinical Research Center, New York University Langone Medical Center, Center of Excellence on Aging, New York, NY 10016, USA Dilip V. Jeste University of California, San Diego, 9500 Gilman Drive, # 0664, La Jolla, CA 92093, USA David Jolley Personal Social Services Research Unit, Manchester University, Manchester M13 9PL, UK Rob Jones Mental Health Services for Older People Directorate and Nottingham University Section of Old Age Psychiatry, Queen’s Medical Centre, Nottingham NG7 2UH, UK Anthony Francis Jorm ORYGEN Research Centre, Department of Psychiatry, University of Melbourne, Parkville, Victoria 3052, Australia Eileen M. Joyce UCL Institute of Neurology, Queen Square, London WC1N 3BG, UK Andrea June University of Colorado at Colorado Springs, Colorado Springs, CO 80918, USA Barbara Kamholz Department of Psychiatry, Duke University, Durham, NC 27708, USA Jason Karlawish University of Pennsylvania Institute on Aging, Philadelphia, PA 19104, USA
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CONTRIBUTORS
Robert J. Kastenbaum Arizona State University at Tempe, Tempe, AZ 85287, USA
David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
Cornelius Katona Department of Mental Health Sciences, University College London, Charles Bell House, 7-73 Riding House Street, London WIW 7EJ, UK
Vanessa Lawrence Institute of Psychiatry, King’s College London, 16 De Crespigny Park, London, SE5 8AF, UK
Sharjeel Khan Aging and Dementia Clinical Research Center, New York University Langone Medical Center, Center of Excellence on Aging, New York, NY 10016, USA
Orly Lazarov Department of Anatomy and Cell Biology, College of Medicine, The University of Illinois at Chicago, Chicago, IL 60612, USA
Zunera Khan King’s College London, London SE1 1UL, UK
Barry D. Lebowitz University of California, San Diego School of Medicine, 9500 Gilman Drive, La Jolla, CA 92093, USA
Jeanne Kim Memory and Aging Research Center, Geriatric Psychiatry Division, Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine at UCLA, 760 Westwood Plaza, Suite 88-201, Los Angeles, CA 90024, USA
Susan W. Lehmann Department of Psychiatry and Behavioral Sciences, The Johns Hopkins University School of Medicine, 600 North Wolfe Street, Meyer 279, Baltimore, MD 21287-7279, USA
Susan Kim Geriatric Psychiatry Research Program, McLean Hospital, 115 Mill Street, Belmont, MA 02478, USA
Alex D. Leow Department of Psychiatry, University of Illinois at Chicago, Chicago, IL 60637, USA
Paul D. Kirwin Associate Professor of Psychiatry, Geriatric Psychiatry Fellowship Director, Yale University School of Medicine, VA CT Healthcare System
James Lindesay Department of Health Sciences, University of Leicester, Leicester LE5 4PW, UK
Eran Klein The Johns Hopkins Berman Institute of Bioethics, Baltimore, MD 21201, USA Alan Kluger Aging and Dementia Clinical Research Center, New York University Langone Medical Center, Center of Excellence on Aging, New York, NY 10016, USA Anthony Klugman Old Age Psychiatry, South London and Maudsley NHS Foundation Trust, Bethlem Royal Hospital, Monks Orchard Road, Beckenham, Kent, BR3 3BX, UK Robert Kohn The Warren Alpert Medical School of Brown University, Miriam Hospital, 164 Summit Ave, Fain Building Suite 2B, Providence, RI 02906, USA Maritha J. Kotze Department of Pathology, Faculty of Health Sciences, Stellenbosch University, Tygerberg, 7505, Cape Town, South Africa Peter Knapp School of Healthcare, University of Leeds, Leeds LS2 9JT, UK Anand Kumar Department of Psychiatry, University of IllinoisChicago, 912 South Wood Street, Chicago, IL 60637, USA Yookyung Kwon Stanford Geriatric Education Center, 1215 Welch Road, Stanford, CA 94304-5403, USA
Benjamin Liptzin Department of Psychiatry, Baystate Medical Center, 759 Chestnut Street, Springfield, MA, 01199, USA Gill Livingston Department of Mental Health Sciences, University College London, London W1W 7EJ, UK Constantine G. Lyketsos The Johns Hopkins Bayview Medical Center 5300 Alpha Commons Drive Alpha Commons Building, 4th Floor, Baltimore, MD 21224, USA David Aaron Maroof Department of Psychiatry and Behavioral Sciences, The Johns Hopkins University School of Medicine, 600 North Wolfe Street, Meyer 218, Baltimore, MD 21287-7218, USA Renee Marquett Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Road, Stanford, CA 94305-5717, USA Meghan A. Marty University of Colorado at Colorado Springs, Colorado Springs, CO 80918, USA E. Wayne Massey Duke University School of Medicine, Duke University Medical Center, Durham, NC 27710, USA Fiona E. Matthews MRC Biostatistics Unit, Institute of Public Health, Cambridge, CB2 2SR, UK
Helen H. Kyomen McLean Hospital, 115 Mill Street, Belmont, MA, 02478, USA
Cecilia Mattisson Department of Clinical Sciences, Psychiatry, The Lundby Study, Lund University Hospital, SE-221 85 Lund, Sweden
Iain Lang Peninsula Medical School, University of Exeter, Plymouth, PL6 8BU, UK
Donna D. McAlpine School of Public Health, University of Minnesota, Minneapolis, MN 55455, USA
Nicole M. Lanouette University of California, San Diego, 9500 Gilman Drive, # 0664, La Jolla, CA 92093, USA
William M. McDonald Fuquay Center for Late Life Depression, Emory University School of Medicine, Atlanta, GA 30329-5120, USA
Maria I. Lapid Mayo Clinic College of Medicine, Mayo Clinic Rochester, Rochester, MN 55905, USA Helen Lavretsky Departments of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior,
Bernadette McGuinness Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, The Queen’s University of Belfast, Belfast BT9 7BL, UK
CONTRIBUTORS
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I. G. McKeith Department of Old Age Psychiatry, Institute for Health of the Elderly, Wolfson Research Centre, Newcastle General Hospital, Newcastle upon Tyne NE4 6BE, UK
Per Nettelbladt Department of Clinical Sciences, Psychiatry, The Lundby Study, Lund University Hospital, SE-221 85 Lund, Sweden
David Mechanic Institute for Health, Health Care Policy and Aging Research, Rutgers, the State University of New Jersey, New Brunswick, NJ 08901, USA
Ruth O’Hara Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford University, Stanford, CA 94305, USA
David Melzer Peninsula College of Medicine & Dentistry, Universities of Exeter and Plymouth, John Bull Building, Plymouth, PL6 8BU, UK
VA Sierra-Pacific Mental Illness Research Education and Clinical Center, Palo Alto, USA
Mario F. Mendez Departments of Neurology and Psychiatry, VA Greater Los Angeles Healthcare System and David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA David A. Merrill Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA and VA Greater Los Angeles Healthcare System Sujatha Merve Chasefarm Hospital, Enfield EN2 8JL, UK Catherine Messinger University of Iowa College of Nursing, 101 Nursing Building, 50 Newton Road, Iowa City, IA 52242-1121, USA Karen Miller Aging and Memory Research Center, Geriatric Psychiatry Division, Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine at UCLA, 760 Westwood Plaza, Suite 88-201, Los Angeles, CA 90024, USA Alisoun Milne School of Social Policy, Sociology and Social Research, University of Kent, Canterbury, Kent CT2 7LZ, UK Gary S. Moak University of Massachusetts Medical School, Worcester, MA and Medical Director, Moak Center for Healthy Aging, 18 Lyman Street, Suite 285 Westborough, MA 01581, USA Victor Molinari University of South Florida, Tampa, FL 33620, USA Isabel Monteiro Aging and Dementia Clinical Research Center, New York University Langone Medical Center, Center of Excellence on Aging, New York, NY 10016, USA John C. Morris Department of Neurology, Washington University School of Medicine, 660 S. Euclid Avenue, St. Louis, MO 63110, USA Pat Mottram Evidence Based Practice Centre, Department of Psychiatry, University of Liverpool 147, UK Cynthia A. Munro Department of Psychiatry and Behavioral Sciences, The Johns Hopkins University School of Medicine, 600 North Wolfe Street, Meyer 218, Baltimore, MD 21287-7218, USA Declan G. M. Murphy Department of Forensic and Neurodevelopmental Sciences, Institute of Psychiatry at the Maudsley, King’s College London WC2R 2LS, UK
John O’Hare Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, The Queen’s University of Belfast, Belfast BT9 7BL, UK Esther Oh Johns Hopkins School of Medicine and Johns Hopkins Bayview, Baltimore, MD 21224, USA Martin Orrell Department of Mental Health Sciences, 48 Riding House Street, University College London, London W1W 7EY, UK Dana Scherr Parchi The Child and Family Institute at St. Luke’s and Roosevelt Hospitals, New York, NY 10025, USA Laura Parisi Clinica Neurologica University Campus Bio-Medico, Rome, Italy A. Peter Passmore Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, The Queen’s University of Belfast, Belfast BT9 7BL, UK Vikram Patel London School of Hygiene and Tropical Medicine (UK) and Sangath (India); Sangath Centre, 841/1 Alto Porvorim, Goa 403521, India Thomas L. Patterson Department of Psychiatry, University of California – San Diego, MC 0680, 9500 Gilman Drive, La Jolla, CA 92093-0680, USA Ian Peate School of Nursing and Midwifery, Thames Valley University, London W5 5RF, UK Renee Pepin University of Colorado at Colorado Springs, Colorado Springs, CO 80918, USA Robert Perneczky Klinik und Poliklinik f¨ur Psychiatrie und Psychotherapie, Klinikum rechts der Isar, Technische Universit¨at M¨unchen, Ismaninger Str. 22, 81675 M¨unchen, Germany Richard Perry Department of Neurosciences, Imperial College and Imperial College Healthcare NHS Trust, Charing Cross Hospital, Fulham Place Road, London, W6 8RF, UK Adolf Pfefferbaum Neuroscience Program, SRI International, 333 Ravenswood Ave., Menlo Park, CA 94025, USA
Joanna Murray Institute of Psychiatry, King’s College London, 16 De Crespigny Park, London, SE5 8AF, UK
Michael Philpot Mental Health of Older Adults, South London and Maudsley NHS Foundation Trust, Maudsley Hospital, London SE5 8AZ, UK
Asim Naeem Division of Mental Health (Psychiatry of Disability), Level 6 – Hunter Wing, St George’s University of London, Cranmer Terrace, London, SW17 0RE, UK
Ben Pickard Strathclyde Institute of Pharmacy and Biomedical Sciences (SIPBS), University of Strathclyde, The John Arbuthnott Building, 27 Taylor Street, Glasgow, G4 0NR, UK
xviii
CONTRIBUTORS
Felix C.V. Potocnik Department of Psychiatry, Faculty of Health Sciences, Stellenbosch University, Tygerberg, 7505, Cape Town, South Africa
M. Sajatovic Case Western Reserve University School of Medicine and University Hospitals Case Medical Center, Cleveland, OH, 44106, USA
Bevin Powers VA Sierra-Pacific Mental Illness Research Education and Clinical Center, Veterans Administration Health Care System, Palo Alto, CA 94304, USA
Oludamilola Salami Johns Hopkins School of Medicine and Johns Hopkins Bayview, Baltimore, MD 21224, USA
Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, USA Aparna Prasanna Wolverhampton Primary Care Trust, Penn Hospital, Wolverhampton WV4 5HN, UK Neil Prentice Murray Royal Hospital, Perth PH2 7BH, UK Martin Prince Centre for Global Mental Health, Department of Health Service and Population Research, Institute of Psychiatry, King’s College London, 16 De Crespigny Park, London, SE5 8AF, UK Patrick Rabbitt Age and Cognitive Performance Research Centre, University of Manchester, Oxford Road, Mancehster M13 9PL, UK Peter V. Rabins Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA Oyepeju Raji Division of Mental Health (Psychiatry of Disability), Level 6 – Hunter Wing, St George’s University of London, Cranmer Terrace, London, SW17 0RE, UK
George M. Savva Department of Public Health and Primary Care, University of Cambridge, Institute of Public Health, Cambridge CB2 0SR, UK Stephen M. Scheinthal New Jersey Institute for Successful Aging, University of Medicine and Dentistry of New Jersey – School of Osteopathic Medicine, Stratford, NJ 08084, USA Martin M. Schmidt Division of Mental Health, St George’s University of London, London SW17 0RE, UK Jerome J. Schulte Department of Psychiatry, Wright State University, Boonshoft School of Medicine, OH 3640, USA Daniel L. Segal University of Colorado at Colorado Springs, Colorado Springs, CO 80918, USA Sati Sembhi Suffolk Mental Health Partnership NHS Trust, St Clement’s Hospital, Foxhall Road, Ipswich, Suffolk IP3 8LS, UK Andrew Moore Severn Department of Anaesthesia, Royal Lancaster Infirmary, Lancaster LA1 4RP, UK K.S. Shaji Department of Psychiatry, Government Medical College, Thrissur, Kerala 680596, India
Barry Reisberg New York University Langone Medical Center, Center of Excellence on Aging, New York, NY 10016, USA
Bart Sheehan Health Sciences Research Institute, Medical School Building, Warwick Medical School, Coventry CV4 7AL, UK
Kenneth Rockwood Division of Geriatric Medicine, Dalhousie University, 1421–5955 Veterans’ Memorial Lane, Halifax, NS, B3H 2E1, Canada
Melanie B. Shulman Aging and Dementia Clinical Research Center, New York University Langone Medical Center, Center of Excellence on Aging, New York, NY 10016, USA
Joanne Rodda Department of Mental Health Sciences, University College London, WC1E 6BT, UK
K.I. Shulman Sunnybrook Health Sciences Centre, Toronto, Ontario, M4N 3M5, Canada
Heather R. Romero Joseph and Kathleen Bryan Alzheimer’s Disease Research Center, Department of Psychiatry. Duke University, Durham, NC 27705, USA
Marcus Simmgen Thomas Addison Unit, St George’s Hospital NHS Trust, Blackshaw Road, Tooting, London SW17 0QT, UK
Steven P. Roose College of Physicians and Surgeons, Columbia University, and Division of Geriatric Psychiatry, New York State Psychiatric Institute, New York, NY 10032, USA Paolo Maria Rossini Clinica Neurologica University Campus BioMedico, Rome, Italy Teresa A. Rummans Mayo Clinic College of Medicine, Mayo Clinic Rochester, Rochester, MN 55905, USA Marwan Sabbagh Cleo Ruberts Center, Banner-Sun Health Research Institute, Sun City, AZ 85351, USA Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden Sunita Sahu Oxleas NHS Foundation Trust, Memorial Hospital, Shooters Hill, London, SE18 3RZ, UK
Ingmar Skoog Institute of Neuroscience and Physiology, Unit of Neuropsychiatric Epidemiology, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden Gary W. Small Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA Gary W. Small Parlow-Solomon Filip Smit Professor of Public Mental Health Trimbos Institute (Netherlands Institute of Mental Health and Addiction) and EMGO Institute of Health and Health Care Research, VU University Medical Centre. PO Box 725, Utrecht 3500 AS, The Netherlands B. Joy Snider 660 S. Euclid Avenue, CB 8111, Department of Neurology, Washington University in St Louis, St. Louis, MO 63110, USA
CONTRIBUTORS
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Christian Sorg Klinik und Poliklinik f¨ur Psychiatrie und Psychotherapie, Klinikum rechts der Isar, Technische Universit¨at M¨unchen, Ismaninger Str. 22, 81675 M¨unchen, Germany
Stephen Todd Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, The Queen’s University of Belfast, Belfast BT9 7BL, UK
Reisa A. Sperling Memory Disorders Unit, Brigham and Women’s Hospital, Alzheimer’s Disease Research Center and Gerontology Research Unit, Massachusetts General Hospital, Department of Neurology and Psychiatry, Harvard Medical School, Boston, MA 02215, USA
Carol Torossian Aging and Dementia Clinical Research Center, New York University Langone Medical Center, Center of Excellence on Aging, New York, NY 10016, USA
D. C. Steffens Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC 3702, USA Dan J. Stein Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa Elliott M. Stein Jewish Home of San Francisco, 302 Silver Avenue San Francisco, CA 94112, USA and Department of Psychiatry, University of Miami School of Medicine, Miami, FL 33136, USA Max L. Stek Department of Psychiatry, VUmc Medical Centre and GGZinGeest, AJ Ernst street 887, 1081HL Amsterdam, The Netherlands Martin Steinberg Johns Hopkins Bayview Medical Center, 5300 Alpha Commons Drive, Baltimore, MD 21224, USA Robert Stewart King’s College London (Institute of Psychiatry), De Crespigny Park, London SE5 8AF, UK Mary Ellen Stolder University of Iowa College of Nursing, 101 Nursing Building, 50 Newton Road, Iowa City, IA 52242-1121, USA David L. Sultzer Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA and VA Greater Los Angeles Healthcare System 11301 Wilshire Blvd. Los Angeles, CA 90073, USA
Adrian Treloar Oxleas NHS Foundation Trust, Memorial Hospital, Shooters Hill, London, SE18 3RZ, UK JoAnn T. Tschanz Department of Psychology and Center for Epidemiologic Studies, Utah State University, Logan, UT 84322, USA Joshua Tsoh Associate Consultant in Psychiatry, Prince of Wales Hospital, Shatin, New Territories, Hong Kong Debby Tsuang Geriatric Research, Education, and Clinical Center and Mental Illness Research, Education, and Clinical Center, Veterans Affairs Puget Sound Health Care System, Seattle, WA 98108, USA H. W. J. van Marwijk Department of General Practice, VUmc Medical Centre and GGZinGeest, AJ Ernst street 887, 1081HL Amsterdam, The Netherlands Susan J. van Rensburg Division of Chemical Pathology, National Health Laboratory Service, Sandringham, Cape Town, South Africa Vijay Venkatraman University of Pittsburgh School of Medicine, Pittsburgh, USA Martin J. Vernon Department of Elderly Medicine, Burton House, Withington Hospital, Nell LAne, West Didsbury, Manchester M20 8LR, UK
Edith V. Sullivan Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Rd., Stanford, CA 94305, USA
Ottavio V. Vitolo Memory Disorders Unit, Brigham and Women’s Hospital, Massachusetts General Hospital, Department of Psychiatry, Harvard Medical School, Boston, MA 02215, USA
Cindy Tam Department of Psychiatry, The Chinese University of Hong Kong, Shantin, New Territories, Hong Kong
Zuzana Walker Department of Mental Health Sciences, St Margaret’s Hospital, Epping, Essex, CM16 6TN UK
Giles MY Tan Department of Forensic and Neurodevelopmental Sciences, Institute of Psychiatry at the Maudsley, King’s College London WC2R 2LS, UK
John P. Wattis Professor of Old Age Psychiatry, Centre for Health and Social Care Research, University of Huddersfield, Queensgate, Huddersfield HD1 3DH, UK
Rawan Tarawneh Department of Neurology, Washington University in St Louis, 660 S. Euclid Avenue, CB 8111, St. Louis, MO 63110, USA
Jerzy Wegiel New York State Institute for Basic Research in Developmental Disabilities, Staten Island, New York 10306, USA
John-Paul Taylor Department of Old Age Psychiatry, Institute for Health of the Elderly, Wolfson Research Centre, Newcastle General Hospital, Newcastle upon Tyne NE4 6BE, UK
Kathleen A. Welsh-Bohmer Joseph and Kathleen Bryan Alzheimer’s Disease Research Center, Department of Psychiatry. Duke University, Durham, NC 27705, USA
Alexander M. Thomson Department of Elderly Care, Salford Royal Hospitals NHS Foundation Trust, Stott La, Salford M68HD, UK
Eric Wexler Division of Geriatric Psychiatry and Center for Neurobehavioral Genetics, David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
Dolores Gallagher-Thompson Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Road, Stanford, CA 94305-5717, USA
Kirsten M. Wilkins Assistant Professor of Psychiatry, University of Oklahoma College of Medicine-Tulsa, Tulsa, OK
Paul M. Thompson Department of Neurology, UCLA David Geffen School of Medicine, Los Angeles, CA 90095, USA
David G. Wilkinson Moorgreen Hospital, Botley Road, West End, Southampton SO30 3JB, UK
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CONTRIBUTORS
Philip Wilkinson Department of Psychiatry, University of Oxford, Warneford Hospital, Old Road, Headington, Oxford OX3 7JX, UK Kenneth C. M. Wilson St Catherine’s Hospital, Church Road, Birkenhead, Wirral L42 OLQ, UK Anders Wimo KI Alzheimer’s Disease Research Center, Department of Neurobiology, Care Sciences and Society, Karolinska institutet, Stockholm, Sweden
Graeme A. Yorston St Andrew’s Hospital, Northampton NN1 5DG, UK Chang-En-Yu Geriatric Research, Education, and Clinical Center and Mental Illness Research, Education, and Clinical Center, Veterans Affairs Puget Sound Health Care System, Seattle, WA 98108, USA Natalie M. Zahr Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 401 Quarry Rd., Stanford, CA 94305, USA
Philip Wong Johns Hopkins School of Medicine and Johns Hopkins Bayview, Baltimore, MD 21224, USA
L. McKenzie Zeiss University of California, Irvine, CA 926972800, USA
Matthew R. Woodward Geriatric Psychiatry Research Program, McLean Hospital, Belmont, MA 02478, USA
Richard A. Zweig Ferkauf Graduate School of Yeshiva University, Bronx, NY 10461, USA
Preface
It has been eight years since the second edition of Principles and Practice of Geriatric Psychiatry was published. During this time there has been substantial progress in the science and practice of geriatric psychiatry. This third edition attempts to capture these advances and provide an up-to-date summary for trainees and practitioners. Two of the Editors of the previous editions, John R M Copeland and Dan G Blazer, decided to withdraw and two new Editors (one from the UK and one from the US) have been recruited. We wish first of all to express our grateful thanks to John and Dan for their remarkable stewardship over the production of the two previous editions. We would also like to acknowledge the invaluable contribution of the six Associate Editors in bringing this third edition to completion. The previous edition received good reviews as well as some helpful criticisms. We therefore decided to maintain the textbook’s overall scope, structure, headings, list of contents and international authorship. The majority of the textbook’s chapters have been updated by the original authors. We have, however, recruited several new
authors who are internationally recognized experts in their fields and commissioned substantial completely new material. We believe that the value and the strengths of this textbook rest in its comprehensive coverage of the basic and clinical sciences of normal and abnormal ageing, of the full range of psychiatric disorders in the elderly, and of the organization of psychogeriatric services in the UK and the US as well as chapters on prevention, training and education. We hope that this third edition is well received by its readers and that it proves to be a useful and readable way for them to update their knowledge of the science and practice of geriatric psychiatry.
Mohammed T Abou-Saleh Cornelius L E Katona Anand Kumar
Preface to Second Edition
The editors were very gratified that the first edition of this textbook was generally well received and that a second edition has been called for. It is now seven years since the original book appeared, and there have been many more advances in the subject. In spite of new sections and some wholesale rewriting, it has been possible once again, to contain the information in one volume. Very sadly some of our original contributors have died. New authors have replaced them while others have been added in an endeavour to keep the text authoritative and up-to-date. The helpful criticisms of the first edition have been carefully considered in the preparation of this one. Having so many distinguished authors with such a breadth of interest, while
greatly enhancing the book, has led to a long gestation period, but we believe that it has been worthwhile. Much of the original format has been retained in order to continue to stimulate lively debate and exchange of views. If the book contributes to the growing strength of Geriatric Psychiatry internationally, it will have done its work.
John R. M. Copeland Mohammed T. Abou-Saleh Dan G. Blazer
Preface to First Edition
The discipline of the psychiatry of old age has moved rapidly in recent years and the number of practitioners has expanded worldwide. An authoritative text is required which draws on the knowledge of these experts and which reflects both new scientific advances and innovations in service development. In a comparatively new subject many of the issues are still contentious and on some of these we have tried to provide the opportunity for the expression of different points of view. Readers are asked to judge the issues for themselves from the evidence set out. Here and there short, special articles have been commissioned which present research findings in more detail and describe new aspects of care. They are intended to enliven the text and their choice has been dependent on timing and opportunity. We have also tried to give a “feel” for what is happening in developing countries and the scope of the problems experienced by local practitioners.
Even a book of this size can never be complete and no doubt gaps in the coverage of subjects will be identified. We would be glad to have them pointed out. The more comprehensive a book aims to be the longer it takes to come to publication and in a fast-moving area of knowledge this can be a problem. Many of our authors have been kind enough to update their contributions at a late stage, which we hope has overcome this difficulty to some extent. In the early stages of the development of a subject there is insufficient corpus of knowledge to assemble in book form. This situation has changed dramatically for geriatric psychiatry in recent years. We hope that the knowledge gathered here from our distinguished international panel of authors bears this out.
John R. M. Copeland Mohammed T. Abou-Saleh Dan G. Blazer
.
Part A
Historical Background
.
1
A Conceptual History in the Nineteenth Century German E. Berrios Department of Psychiatry, Addenbrooke’s Hospital, Cambridge, UK
The history of geriatric psychiatry can be written from two viewpoints. The ‘externalist’ approach focuses on the social and political variables that have controlled attitudes towards abnormal behaviour in old age, and on the professionalization of those charged with the care of the mentally infirm elderly. The ‘internalist’ approach – to be followed in this chapter – concentrates on the origin of the scientific language of psychogeriatrics. An adequate historical account should include information on theories of ageing, both physical and mental, brain sclerosis and the formation of a viable concept of mental illness. On the first rubric much research has been done1 – 9 ; far less work exists on the other two. On psychogeriatric care before the nineteenth century10,11 there is very little: this may simply reflect a historical reality.
VIEWS ON AGEING BEFORE THE NINETEENTH CENTURY Like most other aspects of human life, ageing has also been portrayed in terms of metaphors. Classical views, following the nature–nurture controversy, conceived of ageing as resulting from either internal instructions or from the buffeting of foreign factors4,8 . The ‘wear and tear’ view happened to be popular during the early nineteenth century, the period on which this chapter will concentrate. It was based, as it had always been, on the ageless observation that all natural objects, whether animate or not, are subject to the ravages of time. Surprisingly enough, the ‘wear and tear’ view has not always generated an understanding attitude. In fact, across times and cultures great ambiguity has existed in regard to the treatment of old folk. Fortunately, a realistic acceptance seems to have predominated although there is plenty of evidence of hostility. The Hebrew tradition, and indeed its Christian offshoot, encouraged much reverence towards the wisdom and value of old age. But even in societies that have made great play of this view, veneration has been reserved for those in positions of power or influence12 . Little is known about attitudes towards elderly women or old men in humbler stations11 . So, it can be concluded that, all in all, a view seems to have predominated that ageing was undesirable and that the identification of wear factors was important to devising ways of prolonging life5,13 . A second ambiguity can be detected in these earlier writings. It concerns the extent to which the ageing process necessarily involves the human mind. While it was a palpable fact that all human frames decayed, not everyone accepted that this had necessarily to affect the soul or mind. Extant descriptions of the psychological changes
brought about by old age suggest that people were aware that the mind also underwent a decline. However, theory and religion encouraged the view that the spirit could or did escape wear and tear, and that human beings grew ever more wise and useful, thanks to the accumulation of experience and knowledge. This belief must have been available in all those societies that felt the need to create adequate spaces for all manner of intellectual and/or sociopolitical gerontocracies2 . Some seem even to have separated chronological age and functional age in order to justify such concessions. From the point of view of the history of psychogeriatrics, it would be useful to know to what extent this belief was undermined by the occasional case of dementia among those elderly in positions of power1 . Historical evidence seems to show that these situations were neither more nor less perturbing than mental illness occurring at other periods of life. Indeed, fail-safe devices seem to have been available in these societies to cope with the upheavals created by such occurrences. Men like Buffon, Darwin and Goethe reshaped ideas on ageing during the eighteenth century. Buffon14 wrote: ‘All changes and dies in Nature. As soon as it reaches its point of perfection it begins to decay. At first this is subtle and it takes years for one to realise that major changes have in fact taken place’ (p. 106). Buffon put this down to an ‘ossification’ process similar to that affecting trees: ‘this cause of death is common to animals and vegetables. Oaks die as their core becomes so hard that they can no longer feed. They trap humidity, and this eventually makes them rot away’ (p. 111). Erasmus Darwin’s views resulted from the application of yet another metaphor, namely that ageing results from a breakdown of ‘communication’ between man and his environment15 . Darwin suggested that such breakdown followed a loss of irritability (a property of nerve fibres) and a decreased response to sensation: It seems our bodies by long habit cease to obey the stimulus of the aliment, which support us . . . three causes may conspire to render our nerves less excitable: 1. If a stimulus be greater than natural, it produces too great an exertion of the stimulated organ, and in consequence exhausts the spirit of animation; and the moving organ ceases to act, even though the stimulus is continued. 2. If excitations weaker than natural be applied, so as not to excite the organ into action, they may be gradually increased, without exciting the organ into action, which will thus acquire a habit of disobedience to the stimulus. 3. When irritative motions continue to be produced in consequence of stimulus, but are not succeeded by sensation. (p. 365)
Principles and Practice of Geriatric Psychiatry, 3rd edn. Edited by Mohammed T. Abou-Saleh, Cornelius Katona and Anand Kumar 2011 John Wiley & Sons, Ltd
4
PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRY
VIEWS ON AGEING DURING THE NINETEENTH CENTURY In 1807 Sir John Sinclair16 published a major compendium on ageing and longevity, which included references to most pre-nineteenth century sources. It was, in a way, the last grand glance to the past. Soon afterwards work started by those who, like L´eon Rostan (1791–1866), based their claims on empirical findings. Rostan, one of the most original members of the Paris school, published in 1819 his Recherches sur le Ramollissement du Cerveau 17 , where the view commenced that vascular disorders might be as important as parenchymal ones in brain ageing. Even more important was his uncompromising anti-vitalistic position enshrined in the claim that all diseases were related to pathological changes in specific organs18,19 . During the 1850s Reveill´e-Parise3 saw his task as writing on ‘the history of ageing, that is, mapping the imprint of time on the human body, whether on its organs or on its spiritual essence’ (p. v). In regard to ageing itself he wrote: ‘the cause of ageing is a gradual increase in the work of decomposition . . . but how does it happen? What are the laws that control the degradation that affects the organization and mind of man?’ (p. 13). Reveill´e-Parise dismissed the toxic view defended by the Italian writer Michel L´evy20 according to which there was a gradual accumulation of calcium phosphates that led to petrification, to an ‘anticipation of the grave’. This view, he stated, had no empirical foundation and was based on a generalization from localized findings. Reveill´e-Parise supported the view that ageing results from a negative balance between composition and elimination, which equally affected the cardiovascular, respiratory and reproductive organs. Finally, the views should be mentioned of J. M. Charcot, who in 1868 offered a series of 24 lectures on the diseases affecting the elderly21 . Charcot dedicated Lecture 1 to the ‘general characters of senile pathology’; he started by saying that all books on geriatrics up to his time had ‘a particularly literary or philosophical turn [and had been] more or less ingenious paraphrases of the famous treatise De Senectute’ (p. 25). He praised Rostan for his views on asthma and brain softening in the elderly, and predictably also mentioned Cruveilhier, Hourman and Dechambre, Durand-Fardel and Prus. He criticized Canstatt and other German physicians because in their work, ‘imagination holds an immense place at the expense of impartial and positive observation’ (p. 26). Charcot’s own contribution was based on the general principle that ‘changes of texture impressed on the organism by old age sometimes become so marked, that the physiological and pathological states seem to merge into one another by insensible transitions, and cannot be clearly distinguished’ (p. 27).
THE DEVELOPMENT OF THE NOTION OF BRAIN SCLEROSIS When in 1833 Lobstein22 described the basic pathology of arteriosclerosis, he did not imagine that it would, during the second half of the century, become the mechanism of ‘senility’ par excellence14,23,24 . Motor and sensory deficits, vertigo, delusions, hallucinations and volitional, cognitive and affective disorder were all attributed to the effect of arteriosclerosis25,26 . They related to the brain via a two-stage speculative pathophysiology: parenchymal and/or vascular disorders could affect the brain, and the distribution of the lesions could be diffused or focal. Vascular changes included acute ischaemia (on which clinical observation was adequate)27,28
and chronic ischaemia, invented as a separate syndrome by extrapolating from the symptoms and signs observed during the acute states24 . The role of arteriosclerosis as a causal and prognostic factor in relation to the involutional psychoses was challenged early in the twentieth century29 but this paper remained unnoticed. Hence, some of the old notions, such as that of ‘arteriosclerotic dementia’, remained active well into the 1960s30 . Alienists during the same period, however, were already able to distinguish between states where a putative chronic and diffuse reduction in blood supply had taken place from focalized damage, i.e. what they called ‘multifocal arteriosclerotic dementia’ and was equivalent to what is currently called multi-infarct dementia24,31,32 .
NINETEENTH CENTURY VIEWS ON MENTAL DECAY IN THE ELDERLY It is against this background that the history of the language and concepts dedicated to understanding mental disorders in the elderly must be understood. In addition to these neurobiological frameworks, a psychological theory that explained the manner of the decline was required. Such a psychopathology was provided by the heuristic combination of associationism, faculty psychology33 , and statistics34 that characterized the early and middle parts of the nineteenth century. Yet another perspective, originating in clinical observation, was added during the 1830s. It led to the realization that, in addition to the well-known forms of mental disorder, the elderly might exhibit specific forms of deterioration, and that these could be related to recognizable brain changes. There is only space in this chapter to deal with two examples: one typifying a ‘specific’ disorder of old age, namely the history of chronic cognitive failure or dementia; the other illustrating the effect of a general mental disorder (melancholia) on the elderly.
THE FORMATION OF THE CONCEPT OF SENILE DEMENTIA The history of the word and concept of dementia before the nineteenth century has been touched upon elsewhere35 . Suffice it to say here that, at the beginning of the nineteenth century, ‘dementia’ had a ‘legal’ and a ‘medical’ meaning and referred to most acquired states of intellectual dysfunction that resulted in serious psychosocial incompetence. Neither age of acquisition nor reversibility was part of its definition. These two dimensions were only incorporated during the nineteenth century and completely changed the semantic territory of the dementia concept. Anecdotal observation of cases of senile dementia abound both in the fictional literature and in historical documents36 , but the concept of ‘senile dementia’, as it is currently understood, only took shape during the latter part of the nineteenth century. Indeed, it could not have been otherwise, as the neurobiological and clinical language that made it possible only became available during this period37,38 . But even after the nosological status of senile dementia had become clearer, there were many who, like Rauzier39 , felt able to state: ‘it may appear either as a primary state or follow most of the mental disorders affecting the elderly’ (p. 615). Following Rogues de Fursac40 , Adrien Pic – the author of one of the most influential geriatric manuals during this period41 – defined senile dementia as: ‘a state of intellectual decline, whether or not accompanied by delusions, that results from brain lesions associated with ageing’ (pp. 364–365). It was against this background that the concept of Alzheimer’s disease,
HISTORICAL BACKGROUND which became the prototype for all senile dementias, was created during the first decade of the twentieth century37 . Recent work has shown that its ‘discovery’ was controlled by ideological forces well beyond what could be described as ‘scientific’37,42 . These forces also introduced unwarranted clinical strictures, such as the exclusion of non-cognitive symptoms43,44 and false age boundaries, which took many years to disappear.
THE FORMATION OF THE CONCEPT OF INVOLUTIONAL MELANCHOLIA The concept of ‘senile or involutional psychoses’, which featured so prominently in Kraepelin’s early classification, included presenile delusional insanity, senile dementia, late catatonia and involutional melancholia45,46 . The reasons that led Kraepelin to separate this group were mostly theoretical, to wit, that they appeared during a period of life when ‘sclerotic’ changes were beginning to occur; the same factor accounted for their bad prognosis46 . The general history of melancholia and depression has been analysed elsewhere47 – 49 . Suffice it to say here that by the 1860s depression was considered to be an independent syndrome resulting from a primary disorder of affect. This meant that hallucinations, delusions and cognitive impairment were secondary to the pathological feelings. This conviction was particularly strong towards the end of the century, when emotional mechanisms became popular in the explanation of most forms of mental disorder50 . By the end of the century the metaphor of depression as a form of ‘reduction’ or ‘loss’ had become firmly established. No better example can be found than the fact that up to 1893 (fourth edition) Kraepelin felt obliged to classify all forms of agitated depression as mania!51
KRAEPELIN AND INVOLUTIONAL MELANCHOLIA Much of the current confusion on the meaning of involutional melancholia can be explained if attention is given to the circumstances of its historical development (for a full analysis of this process and list of references, see Berrios52 ). The conventional story53 – 56 is that up to the seventh edition of his textbook Kraepelin considered involutional melancholia as a separate disease, and that when confronted by the evidence collected by Dreyfus57 , he decided to include it, in the eighth edition, under the general heading of manic depressive insanity. Indeed, this account was first offered by Kraepelin himself (see Dreyfus, p. 169). The story is, however, more complex and it is unlikely that the findings of Dreyfus alone caused Kraepelin’s change of heart. For example, Thalbitzer58 claimed that his own work had also been influential (p. 41). In the eighth edition Kraepelin abandoned not only involutional melancholia but the entire group of ‘senile psychoses’. A recent statistical analysis of Dreyfus’s old series has also shown that his conclusion that the natural history of involutional melancholia was no different from that of depression affecting younger subjects was wrong51 .
CONCLUSIONS This short chapter, providing a historical vignette on the origin of the language of old age psychiatry, suggests that it was born during the nineteenth century from three conceptual sources: theories of ageing, neurobiological hypotheses concerning brain sclerosis, and
5
the realization that specific forms of mental disorder might affect the elderly. Two clinical illustrations were provided, one pertaining to the origins of the concept of senile dementia, and the other to the notion of involutional melancholia.
REFERENCES 1. Huber J-P, Gourin P. Le vieillard d´ement dans l’Antiquit´e classique. Psychiatr Fr 1987; 13: 12–18. 2. Minois G. Histoire de la Vieillesse. De l’Antiquit´e a` la Renaissance. Paris: Fayard, 1987. 3. Reveill´e-Parise JH. Trait´e de la Vieillesse. Paris: Bailli`ere, 1853. 4. Grmek MD. On Ageing and Old Age. The Hague: W Junk, 1958. ˆ 5. Legrand MA. La Long´evit´e a` Travers les Ages. Paris: Flammarion, 1911. 6. Freeman JJ. Aging. Its History and Literature. New York: Human Sciences Press, 1979. 7. Kotsovsky D. Le probl`eme de la vieillesse dans son d´eveloppement historique. Riv Biol 1931; 13: 99–111. 8. Grant RL. Concepts of aging: an historical review. Persp Biol Med 1963; 6: 443–78. 9. Bastai P, Dogliotti GC. Physiopathologie de la Vieillesse. Paris: Masson, 1938. 10. Robinson DR. The evolution of geriatric psychiatry. Med Hist 1972; 16: 184–93. 11. Kastenbaum R, Ross B. Historical perspectives on care. In Howells J (ed.), Modern Perspectives in the Psychiatry of Old Age. Edinburgh: Churchill Livingstone, 1975, 421–49. 12. Cicero. De Senectute, De Amicitia, De Divinatione, trans. Falconer WA. London: Loeb, 1923. 13. Gruman GJ. A history of ideas about the prolongation of life. Trans Am Phil Soc 1966; 56: 1–97. 14. Buffon M le Comte, Georges-Louis Leclerc. Histoire Naturelle de l’Homme, de la Vieillesse et de la Mort , vol. 4: Histoire Naturelle de l’Homme. Paris: De L’imprimerie Royale, 1774. 15. Darwin E. Zoonomia; or, the Laws of Organic Life, 2 vols. London: Johnson, 1794–1796. 16. Sinclair Sir J. The Code of Health and Longevity. Edinburgh: Constable, 1807. 17. Rostan LL. Recherches sur le Ramollissement du Cerveau. Paris: Bechet, 1819 and 1823. 18. Rostan LL. Jusqu a` quel point l’anatomie pathologique peut-elle e´ clairer la th´e rapeutique des maladies. Th`ese de concours. Paris: Moessard, 1833. 19. Chereau A. Rostan. In Dechambre A, Lereboullet L (eds), Dictionnaire Encyclop´edique des Sciences M´edicales, vol. 84. Paris: Masson, 1877, 238–40. 20. L´evy M. Trait´e d’hygi`ene Publique et Prive´e . Paris: Bailli`ere 1850. 21. Charcot JM. Clinical Lectures on Senile and Chronic Diseases, trans. Tuke WS. London: The New Sydenham Society, 1981. 22. Lobstein JG. Trait´e de Anatomie Pathologique, vol. 2. Paris: Bailli`ere, 1838. ´ 23. Demange E. Etude Clinique et Anatomopathologique de la Vieillesse. Paris: Ducost, 1886. 24. Potain C. Cerveau (Pathologie). In Dechambre A, Lereboullet L (eds), Dictionnaire Encyclop´edique des Sciences M´edicales, vol. 14. Paris: Masson, 1873, 214–345. 25. Marie A. D´emence. Paris: Doin, 1906. 26. Albrecht T. Manischdepressiven Irresein und Arteriosklerose. Allg Z Psychiatr 1906; 63: 402–47.
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27. Schiller F. Concepts of stroke before and after Virchow. Med Hist 1970; 14: 115–31. 28. Fields WS, Lamak NA. A History of Stroke. New York: Oxford University Press, 1989. 29. Walton GL. Arteriosclerosis probably not an important factor in the etiology and prognosis of involution psychoses. Boston Med Surg J 1912; 167: 834–6. 30. Weitbrecht HJ. Psychiatrie im Crundriss. Berlin: Springer, 1968. 31. Ball B, Chambard E. D´emence. In Dechambre A, Lereboullet L (eds), Dictionnaire Encyclop´edique des Sciences M´edicales, vol. 26. Paris: Masson, 1882, 559–635. 32. Spielmeyer W. Die Psychosen des R¨uckbildungs und Creisenalters. Leipzig: Deuticke, 1912. 33. Berrios GE. Historical background to abnormal psychology. In Miller E, Cooper PJ (eds), Adult Abnormal Psychology. Edinburgh: Churchill Livingstone, 1988, 26–51. 34. Birren JE. A brief history of the psychology of ageing. Gerontologist 1961; 1: 69–77. 35. Berrios GE. Dementia during the seventeenth and eighteenth centuries: a conceptual history. Psychol Med 1987; 17: 829–37. 36. Torack RM. The early history of senile dementia. In Reisberg B (ed.), Alzheimer’s Disease. New York: Free Press, 1983, 23–8. 37. Berrios GE. Alzheimer’s disease: a conceptual history. Int J Geriatr Psych 1990; 5: 355–65. 38. Schwalbe J. Dementia senilis. In Lehrbuch der Greisenkrankheiten. Stuttgart: Enke, 1909, 479–89. 39. Rauzier G. Trait´e des Maladies des Vieillards. Paris: Bailli`ere, 1909. 40. Rogues de Fursac J. Manual de Psiquiatrı a´ , trans. of 5th French edn by Peset J. Valencia: Editorial Pubul, 1921. 41. Pic A. Pr´ecis des Maladies des Vieillards. Paris: Doin, 1912. 42. Dillman R. Alzheimer’s Disease. The Concept of Disease and the Construction of Medical Knowledge. Amsterdam: Thesis Publishers, 1990. 43. Berrios GE. Non-cognitive symptoms and the diagnosis of dementia. Historical and clinical aspects. Br J Psychiat 1989; 154(suppl 4): 11–16.
44. Berrios GE. Memory and the cognitive paradigm of dementia during the 19th century: a conceptual history. In Murray RM, Turner TH (eds), Lectures on the History of Psychiatry. London: Gaskell, 1990, 194–211. 45. Cabaleiro Goas M. Los sindromes psic´oticos de la presenilidad. Actas Luso Esp Neurol Psiquiatr 1955; 14: 17–26. 46. Cabaleiro Goas M. Psicosis preseniles no org´anicocerebrales y su prevenci´on. In Proceedings of I Congreso Nacional de GerontoPsiquiatr´ıa preventiva. Xl Reuni´on de la Sociedad Espa˜nola de Psiquiatr´ıa. Madrid: Liade, 1974, 117–42. 47. Berrios GE. Melancholia and depression during the 19th century: a conceptual history. Br J Psychiatry 1988; 153: 298–304. 48. Berrios GE. Depressive and manic states during the 19th century. In Georgotas A, Cancro R (eds), Depression and Mania. New York: Elsevier, 1988, 13–25. 49. Berrios GE. The history of the affective disorders. In Paykel ES (ed.), Handbook of Affective Disorders, 2nd edn. Edinburgh: Churchill Livingstone, 1992, 43–56. 50. Berrios GE. The psychopathology of affectivity: conceptual and historical aspects. Psychol Med 1985; 15: 745–58. 51. Kraepelin E. Psychiatrie, 4th edn. Leipzig: Meixner, 1893. 52. Berrios GE. Affective symptoms in old age: a conceptual history. Int J Geriatr Psychiatry 1991; 6: 337–46. 53. S´erieux P. Review of Dreyfus’s Melancholie. L’Enc´ephale 1907; 2: 456–8. 54. Post F. The Clinical Psychiatry of Late Life. Oxford: Pergamon, 1965. 55. Kendell RE. The Classification of Depressive Illness. Oxford: Oxford University Press, 1968. 56. Jackson SW. Melancholia and Depression. From Hippocratic Times to Modern Times. New Haven, CT: Yale University Press, 1985. 57. Dreyfus GL. Die Melancholie. Ein Zustandsbild des manischdepressiven Irreseins. Jena: Gustav Fischer, 1907. 58. Thalbitzer S. Emotions and Insanity. London: Kegan Paul, Trench, Trubner, 1926.
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2
The Development of Old Age Psychiatry in the UK Claire Hilton1 and Tom Arie2 1
Central and North West London NHS Foundation Trust, Harrow, UK of Nottingham, Ageing and Disability Research Unit, Nottingham, UK
2 University
Old age psychiatry in Britain was born in the 1960s and 1970s, and came of age at its recognition by the government as a distinct specialty in 1989.i Yet the need for it had been recognized as far back as the 1940s. Why was the gestation so long, and how has it developed in the last twenty years since its recognition? What can we learn from this history?
THE EARLIEST DAYS The likelihood that older people would become major users of psychiatric services was identified during the Second World War. Increasing longevity meant there were more, and even older, old people. Falling birth rates increased the proportion of old people and since more women were in employment it was harder for them to take on traditional caring roles. Some of the more frail older people were cared for in ‘chronic sick’ and mental hospitals, which might be needed for war casualties. Until the 1940s mental and physical ill health in old age had been considered largely irremediable. In the 1940s Marjory Warren, the pioneering geriatrician, demonstrated the scope for rehabilitating old people1 , psychiatrist Felix Post wrote on psychiatric differential diagnosis and multidisciplinary approaches to treatment2 , and Willi Mayer-Gross described how severely depressed old people could improve with electroconvulsive therapy (ECT)3ii . Despite the evidence of successful treatment, older people were not given priority in health policy. In 1942 the Beveridge Report laid the foundations of the ‘welfare state’ and a National Health Service (NHS). However, it stated, ‘It is dangerous to be in any way lavish to old age, until adequate provision has been assured for all other vital needs’4 . After the war, at the instigation of Professor Aubrey Lewis, a psychiatric ‘geriatric unit’ was opened at the Bethlem Hospital in South London, part of the Bethlem-Maudsley postgraduate psychiatric teaching hospital (see Chapter 03). This unit was for functionally ill patients regarded as treatable. Patients with dementia, especially those requiring long stay care, were excluded, in part because of i Originally called ‘psychogeriatrics’, ‘old age psychiatry’ is now more commonly used. However, the former is retained in some contexts, e.g. journal titles such as International Psychogeriatrics. The Royal College of Psychiatrists has a Faculty of the Psychiatry of Old Age, while many clinical departments refer to themselves as ‘Mental Health Services’ for older people or older adults. ii Before antidepressants, ECT was the only effective physical treatment.
opposition from academic psychiatrists who did not see their care as being worthy of study and investigation. We shall touch on matters relating to these early influences, since all run throughout the development of the specialty. In addition, each generation rediscovers the demography of ageing as if it were a new phenomenon. Yet unlike, say, trends in fertility, or in transportation, which cannot be predicted with certainty, we always know the size of prospective populations of older people and the epidemiology of the crucial illnesses5 . Repeatedly, the government has laid plans and failed adequately to implement or fund them, and then has ‘discovered’ afresh the scale of need. In 1950 we hear, ‘It is recognised that the present conditions of financial stringency limit opportunities for action at this time’6 . In 2001, a national service ‘framework’ for older people had no allocated new funding for mental health7 , whereas a parallel framework for mental health for younger people was substantially funded8 . Another initiative in 2007 to improve access to psychological therapies has followed an economic model and has been targeted towards getting unemployed younger people into work, although this may well be changing to become more inclusive across all ages9 . A contrast exists even within Britain: since 2002, Scotland provides both free personal and nursing care, if deemed appropriate after assessment, while England and Wales do not.
WORKING WITH GERIATRICIANS Working with geriatricians is crucial in view of the multiple and interlinked disorders of old people, yet at times this has been erratic. Although active treatment, both physical and mental, was being advocated by the 1940s, geriatrics developed much earlier than psychogeriatrics. This was in part because many early geriatricians saw themselves as holistic practitioners for older people, therefore requesting little psychiatric assistance. The advocacy of Lord Amulree, a civil servant and geriatrician, and the other founders of geriatrics drew the successes of rehabilitation, including emptying hospital beds, to the attention of the government10 . Such a phenomenon did not occur in old age psychiatry until around 1970 when new local services, such as that established at Goodmayes Hospital in 196911 , were drawn to the attention of the Department of Health and Social Security12 : only then it was recognized that a modern approach could reduce bed occupancy, improve outcomes and save money. Until the 1970s old age psychiatry in the UK was
Principles and Practice of Geriatric Psychiatry, 3rd edn. Edited by Mohammed T. Abou-Saleh, Cornelius Katona and Anand Kumar 2011 John Wiley & Sons, Ltd
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characterized by research in clinical treatment, nosology, pathology and epidemiology, with only small pockets of local service innovation. In 1970 there were 200 geriatric medicine consultants13 but only a handful of psychogeriatricians14,15 . By 2006 there were 700 psychogeriatricians16 . Where enthusiastic geriatricians and psychiatrists existed in a particular locality they collaborated. In addition, collaboration between the Royal College of Psychiatrists and the British Geriatrics Society17 since the 1970s has led to the development of guidelines for good practice and working collaboratively18 . Moving services away from isolated mental and ‘chronic sick’ hospitals and their coming together in district general hospitals has given better access to each other’s services. Sometimes this facilitated joint working, but formal joint services were rare. In 1977, a department of Health Care of the Elderly, comprising both medicine and psychiatry working together, along with other relevant disciplines and professions was set up in Nottingham. There was an orthopaedic-geriatric unit, a stroke unit and a continence service, and joint research, along with extensive teaching of medical students and postgraduate trainees of relevant disciplines, and of overseas workers19 – 21 . ‘Memory clinics’ are another development, now widespread, with their roots in both psychogeriatric and geriatric practice in the mid-1980s22 . More recent developments include psychiatric liaison services for patients with acute physical illness in district general hospitals23 . Jointly run ‘intermediate care’ or ‘convalescent’ rehabilitation units for confused older people, especially those recovering from both delirium and physical illness, are also new. Geriatricians and psychiatrists still have much to learn from each other, and ‘seamless’ services remain the ideal. ‘Guidelines for collaboration’ have recently been updated24 .
WORKING WITH PSYCHIATRISTS CARING FOR YOUNGER PEOPLE Before the establishment of the specialty, mentally ill old people requiring secondary care were the responsibility of general psychiatrists, but they rarely showed interest in actually working with them, especially those with dementia. However, some of the pioneering psychogeriatric services, such as Sam Robinson’s in Dumfries (1958)25 , or Brice Pitt’s at Claybury, Essex (1966)26 , emerged in part due to the far sightedness and encouragement of general psychiatrists who were medical superintendents of mental hospitals. Despite such early developments, it took until 1989 for the Royal College of Psychiatrists and the government to agree officially to the creation of the new specialty of old age psychiatry. Until then, lack of recognition meant that it had often been impossible to extract from official statistics adequate data on older people’s use of services, and hence to establish the scale of need for services and for training. Competition for resources is inevitable, so long as resources are limited. The low status of the aged, the perceived needs of people of working age, and the common misperception that young severely mentally ill people are frequently dangerous have generally resulted in funding for services for younger people disproportionately exceeding that for older people.
A CENTRAL BODY FOR COORDINATING DEVELOPMENT A powerful national focus for securing improved recognition and better resources has been the flourishing Faculty of the Psychiatry
of Old Age at the Royal College of Psychiatrists (since 1988), and its predecessor bodies (from 1973). It has, among other things, encouraged research, innovation, multidisciplinary working, and links with voluntary and statutory organizations and with the government, and has taken an interest in architecture and design for elderly confused people27 . A first series of newsletters in the 1980s served as a constructive means of communication among clinicians. A second series since 1996, available online since 2000 (www.rcpsych.ac.uk/college/faculties/oldage/newsletter.aspx), often expresses thoughtful comment related to current clinical and policy dilemmas. Faculty meetings have remained a source of debate, education, inspiration and problem solving. The Faculty’s website is a mine of information (www.rcpsych.ac.uk/college/faculties/oldage.aspx).
RESEARCH AND ACADEMIC DEVELOPMENT Research on older people’s mental health has flourished and has helped the development of evidence-based practice. Sir Martin Roth in the 1950s defined the major diagnostic categories in older people28 , rather as Emil Kraepelin had done 50 years earlier for younger people. Felix Post undertook follow-up studies of treatment of depression and psychotic disorders. Nick Corsellis29 followed by Bernard Tomlinson, Martin Roth30 and Elaine and Robert Perry unpicked the neurochemical and neuropathological features of Alzheimer’s disease31 . Early research by Raymond Levy into lecithin and later tacrine was a forerunner of today’s evidence-based antidementia drugs32 . Difficulty in obtaining funding for research has been characteristic15 . But the growth of the neurosciences, along with the influence of bodies such as the Alzheimer’s Society, has enhanced the scale of funding for research into the dementias, and has attracted able workers. Research has also grown through the development of academic departments of old age psychiatry. The first old age psychiatrist to be appointed professor became head of the joint department of Health Care of the Elderly in Nottingham in 1977. The first professor of old age psychiatry, at Guy’s Hospital, London, was appointed in 1983. The International Journal of Geriatric Psychiatry was started in 1986. In 1989 there were half a dozen professorial departments33 ; now most medical schools have an academic presence for old age psychiatry, and many NHS consultants are involved in teaching medical students and postgraduates. Many other departments in universities are now conducting relevant research, and there are further thriving journals.
TEACHING AND TRAINING Biographical information reveals that many colleagues did not envisage becoming old age psychiatrists, but were inspired by others to do so; they saw and experienced what could be done to help old people. Such effective teaching is crucial15 . Sharing our knowledge with other specialties and disciplines can change the way colleagues respond to elderly mentally ill people – in primary care, in management, in palliative care, social services, learning disability services, voluntary organizations, Citizens Advice Bureaux, and within the multidisciplinary teams within which we work. Other groups that have sought teaching include architects, designers, lawyers and the police. Structured training for old age psychiatrists has also evolved over the years. The earliest psychogeriatricians in the 1960s and 1970s had little or no specific training. Six months’ experience in old age psychiatry is considered valuable for trainees in psychiatry and in
HISTORICAL BACKGROUND general practice. Specialized training for career old age psychiatrists is during the last three years of a six-year psychiatry training scheme. There is a competency-based curriculum34 , and at least two years (full-time equivalent) old age psychiatry in recognized training posts are usually required.
CLINICAL INNOVATION The demise of the vast Victorian mental hospitals, the coming of community care, more liberal mental health legislation and new effective psychopharmacology have all helped to shape the progress of psychiatry since the 1950s. The psychogeriatricians have consistently fought to prevent older people being left behind younger people in new developments. Important classic texts of innovation in old age psychiatry such as In the Service of Old Age by Tony Whitehead (1971)35 deserve particular mention, as do the reports in the 1960s and 1970s of abuses in the unfashionable sectors of care. The Ely Hospital Report (1969)36 was also instrumental in bringing about the Hospital (later Health) Advisory Service (HAS), which advised on the neglected areas of the health service. The HAS was a valuable ally of the early old age psychiatrists, encouraging and spreading good practice. Its first director became an old age psychiatrist upon demitting office37 . Home assessment and support by consultants and other team members was the norm: in some services this is still the usual first point of contact. Initial assessment at home was introduced in the 1960s, in order to evaluate, in the light of knowledge of the home setting, who could be helped without hospital admission, or who might need a medical or a surgical bed rather than psychiatric help. Often the entire management of the patient could be undertaken in the patient’s home. Home assessment and treatment is valued by patients, carers and staff, and it helps to build a close working relationship with the local community, and is popular with medical students. The importance of support for carers of people with dementia has long been recognized. Respite admissions38 , social services day care, help with personal care at home and the Admiral Nurse service established in 1994 (www.fordementia.org.uk/admiral.htm) are important in delivering such support. Psychotherapy, including family therapy with old people and their adult children, dates from the 1960s39 but is still not widespread, despite pockets of enthusiasm40 . In a very few places psychiatric intensive care units, in particular providing care for elderly men with dementia and disruptive behaviours, have evolved, such older people being excluded from similar services for younger people41 . Elsewhere, intensive home treatment teams are appearing for even those with severe mental illness such as would traditionally require admission. Old age psychiatry day hospitals date from the 1950s onwards. They were often a substitute for long stay care for people with chronic mental illness living at home or with their family. More recently they have developed to offer assessment, treatment, rehabilitation and support such as might be beyond the capacity of a social care day centre. They enable some with particularly disruptive behaviours unmanageable by a social care day centre to remain in the community42 . More recently as ‘ethnic minority’ populations have aged, understanding cultural and religious customs and attitudes to mental illness and ageing has become important in many local communities. Other disciplines have developed in parallel to old age psychiatry. The British Psychological Society, for example, established a special
Table 2.1
9 Core features of a service in 2009
Core features are likely to include: Community: assessment, diagnosis, treatment, rehabilitation Inpatients: acute assessment and continuing care Day hospital Memory service Support for carers Liaison service to geriatric, medical and surgical wards Other: planning teaching research liaison with related professions and organizations advocacy for patients advice on medico-legal matters, e.g. mental capacity
interest group for psychologists working with older people in 1980 (www.psige.org/index.php). Without evaluated creativity, we would not have the rich array of services that, despite constraints of limited funding, serve our patients, their relatives and carers. But by no means every service for older people yet has all the components described above (see Table 2.1).
LONG STAY CARE Up to the 1980s, most long stay care for dementia, along with that of aged people with chronic psychosis, took place in hospitals. Local authority residential homes were intended to care for frail old people, but with the passage of time they too increasingly became facilities for demented people, but lacking nursing skills and facilities appropriate to their residents’ needs. During the Thatcher era of the 1980s, long stay care in hospitals was replaced by care in commercial, or, less often, charitable homes. Surveillance of standards in multiple dispersed units became very difficult. Third party inspection and definition of ‘minimum standards’ was instituted by the Blair government43 . Education and training of care home staff, long virtually absent, is now becoming more prevalent. But ‘scandals’ in the care of old people continue, and although they often achieve publicity, they generally evoke less indignation and less remedial action than similar scandals in child care. Fortunately, architects and designers often now devote special skills to the needs of old people.
THE FUTURE Old age psychiatrists, like workers in other health specialties, practise within the context of the structure and culture of society. At the time of writing we enter a recession, with uncertainty about the future, but with ever more evidence of the effectiveness of our interventions. There are more government initiatives. The National Dementia Strategy, emphasizes raising awareness, early diagnosis and intervention, and improving quality of care in dementia, and is welcome on that account. However, the government’s initial financial backing for the strategy amounts to less than 1% of the total annual cost of dementia care. It is hard to believe that this will make any significant impact. In addition it states, ‘Decisions on funding for subsequent years will only be made once we have had the opportunity to consider
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PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRY
the results from the initial demonstrator sites and evaluation work. There is no expectation therefore that all areas will necessarily be able to implement the Strategy within five years’44 . This resonates with previous policies advocating good practice, which are neither mandatory nor adequately funded. A new Mental Capacity Act seeks to provide a statutory framework to protect vulnerable people who are not able to make their own decisions45 . There is also new legislation relating to ‘deprivation of liberty’, significantly affecting people with dementia who lack capacity to decide on their place of care, to determine whether and how they can be confined to a care home or hospital in their best interests. The new Equality Bill should prevent discrimination in services on the basis of chronological age46 . However, it also carries the paradoxical risk that a separate service for old people may be regarded as discriminatory. Challenges to our special services have long arisen from this viewpoint, and we must continue to show that special services for an inherently low status and thus usually neglected group make for better care, and to point to the reasons why. Legal and medical changes, and changes in society, will raise new questions, but the 1970s adage for an old age psychiatrist will continue to be ‘occasional militancy . . . to gain for the elderly a fair share of scant resources, to put them to best use, to make do with too little while wheeling, dealing, and fighting for more’47 .
REFERENCES 1. Warren M. Care of chronic sick. Br Med J 1943; ii: 822–3. 2. Post F. Some problems arising from a study of mental patients over the age of 60 years. J Ment Sci 1944; 90: 554–65. 3. Mayer-Gross W. Electric convulsion treatment in patients over 60. J Ment Sci 1945; 91: 101–3. 4. Beveridge W. Social Insurance and Allied Services (Cmnd 6404). London: HMSO, 1942. 5. Kay DWK, Beamish P, Roth M. Old age mental disorders in Newcastle upon Tyne, Part 1: A study of prevalence. Br J Psychiatry 1964; 110: 146–58. 6. Ministry of Health. Care of the Aged Suffering from Mental Infirmity, report HMC (50) 25. Typescript in King’s Fund Library, London, 1950. 7. Department of Health. National Service Framework for Older People, 2001. At www.dh.gov.uk/en/publicationsandstatistics /publications/publicationspolicyandguidance/DH 4003066, accessed 9 Jan 2010. 8. Department of Health. National Service Framework for Mental Health, 2001. At www.dh.gov.uk/en/Publicationsandstatistics /Publications/PublicationsPolicyAndGuidance/DH 4009598, accessed 9 Jan 2010. 9. Department of Health. Commissioning IAPT for the Whole Community: Improving Access to Psychological Therapies, 2008. At www.dh.gov.uk/en/Publicationsandstatistics/Publications/DH 0 90011, accessed 9 Jan 2010. 10. Exton-Smith AN. Obituary: Lord Amulree. Br Med J 1984; 288: 156. 11. Arie T. The first year of the Goodmayes psychiatric service for old people. Lancet 1970; ii: 1179–82. 12. Fry J. The Keppel Club (1952–74): lessons from the past for the future. Br Med J 1991; 303: 1596–8. 13. Brocklehurst JC. The Geriatric Day Hospital. London: King Edward’s Hospital Fund for London, 1970.
14. Arie T, Jolley D. Psychogeriatrics. In Freeman H. (ed.), A Century of Psychiatry. London: Mosby-Wolfe, 1999, 260–65. 15. Hilton C (ed.). The Development of Old Age Psychiatry from the 1960s until 1989 , Guthrie Trust Witness Seminar, Centre for the History of Medicine, University of Glasgow, 9 May 2008. At www.gla.ac.uk/media/media 107314 en.pdf, accessed 9 Jan 2010. 16. Royal College of Psychiatrists. Workforce Figures for Psychiatrists. London: Royal College of Psychiatrists, 2006. At www.rcpsych.ac.uk/PDF/Results%20for%20the%202006%20 Census%20(2).pdf, accessed 9 Jan 2010. 17. British Geriatrics Society Cerebral Ageing and Mental Health Special Interest Group. At www.bgs.org.uk/Special%20Interest/ cerebral ageing.htm, accessed 9 Jan 2010. 18. British Geriatrics Society and Royal College of Psychiatrists. Joint report on matters relating to the care of psycho-geriatric patients. Br J Psychiatry 1973; 123: News and Notes 2–3. 19. Arie T. Combined geriatrics and psychogeriatrics: a new model. Geriatr Med 1990; April: 24–7. 20. Arie T. Education in the care of the elderly. Bull N Y Acad Med 1985; 61(6): 492–500. 21. Bendall MJ. The interface between geriatrics and psychogeriatrics. Curr Med Lit Geriatr 1988; 1(1): 2–7. 22. Van der Cammen TJM, Simpson JM, Fraser RM, Preker AS, Exton-Smith AN. The memory clinic: a new approach to the detection of dementia. Br J Psychiatry 1987; 150: 359–64. 23. Working Group for Liaison Mental Health Services for Older People, Faculty of Old Age Psychiatry. Who Cares Wins. London: Royal College of Psychiatrists, 2005. At www.bgs.org.uk/PDF Downloads/WhoCaresWins.pdf, accessed 9 Jan 2010. 24. British Geriatrics Society. Guidelines for Collaboration between Physicians of Geriatric Medicine and Psychiatrists of Old Age, BGS Best Practice Guide 3.4, 2007. At www.bgs.org.uk/Publications/Compendium/compend 3-4.htm, accessed 9 Jan 2010. 25. Robinson RA. The organisation of a diagnostic and treatment unit for the aged in a mental hospital. In Psychiatric Disorders in the Aged , report on the World Psychiatric Association Symposium. Manchester: Geigy, 1965, 186–205. 26. Pitt B, interviewed for Oral History of Geriatrics as a Medical Specialty, National Sound Archive, 1991. At http://cadensa.bl.uk/uhtbin/cgisirsi/BLMW1dvUMJ/10190012/9 (summary), accessed 9 Jan 2010. 27. Kemp M. Accommodation for elderly patients with severe dementia, minutes, Group for the Psychiatry of Old Age, Royal College of Psychiatrists 28 Mar 1974 (13), 13 June 1974 (4). 28. Roth M. The natural history of mental disorders in old age. J Ment Sci 1955; 101: 281–301. 29. Corsellis JAN. Mental Illness and the Ageing Brain, Maudsley Monograph 9. London: Oxford University Press, 1962. 30. Roth M, Tomlinson BE, Blessed G. The relationship between qualitative measures of dementia and degenerative change in cerebral grey matter of elderly subjects. Proc R Soc Med 1967; 60: 254–60. 31. Perry EK, Perry RH, Blessed G, Tomlinson B. Necropsy evidence of central cholinergic deficits in senile dementia. Lancet 1977; i: 189. 32. Eagger SA, Levy R, Sahakian BJ. Tacrine in Alzheimer’s disease. Lancet 1991; 337: 989–92.
HISTORICAL BACKGROUND 33. Arie T. Martin Roth and the ‘Psychogeriatricians’. In Davison K, Kerr A. (eds), Contemporary Themes in Psychiatry: A Tribute to Sir Martin Roth. London: Gaskell, 1989, 231–8. 34. Royal College of Psychiatrists. A Competency Based Curriculum for Specialist Training in Psychiatry: Specialist Module in Old Age Psychiatry, 2009. At www.rcpsych.ac.uk/PDF/Old Age Feb09.pdf, accessed 9 Jan 2010. 35. Whitehead T. In the Service of Old Age: The Welfare of Psychogeriatric Patients. Harmondsworth: Penguin, 1970. 36. DHSS. Report of the Committee of Inquiry into Allegations of Illtreatment of Patients and other Irregularities at the Ely Hospital, Cardiff (Cmnd 3975). London: HMSO, 1969. 37. Baker AA. Why psychogeriatrics? Lancet 1974; i: 795–6. 38. De Largy J. Six weeks in, 6 weeks out. A geriatric hospital scheme for rehabilitating the aged and relieving their relatives. Lancet 1957; i: 418–19. 39. Colwell C, Post F. The parent–child relationship in the treatment of elderly psychiatric patients. Ment Health (Lond) 1964; 23: 7–9. 40. Benbow SM, Marriott A. Family therapy with elderly people. Adv Psychiatr Treat 1997; 3: 138–45. 41. Department of Health. Mental Health Policy Implementation Guide: National Minimum Standards for General Adult Services
42. 43.
44.
45.
46.
47.
11
in Psychiatric Intensive Care Units (PICU) and Low Secure Environments, 2002. At www.dh.gov.uk/en/Publicationsandstatistics /Publications/PublicationsPolicyAndGuidance/DH 4010439, accessed 9 Jan 2010. Arie T. Day care in geriatric psychiatry 1978. Age Ageing 1979; 8(suppl): 87–91. Department of Health. Fit for the Future? National Required Standards for Residential and Nursing Homes for Older People (Consultation Document), 1999. At www.dh.gov.uk/en/ Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH 4009506, accessed 9 Jan 2010. Department of Health. Living Well with Dementia: A National Dementia Strategy, 2009. At www.dh.gov.uk/en/socialcare /deliveringadultsocialcare/olderpeople/nationaldementiastrategy /index.htm, accessed 9 Jan 2010. Office of Public Sector Information. Mental Capacity Act 2005 , 2005. At www.opsi.gov.uk/ACTS/acts2005/ukpga 20050009 en 1, accessed 9 Jan 2010. Office of Public Sector Information. Equality Act 2006 , 2006. At www.opsi.gov.uk/acts/acts2006/pdf/ukpga 20060003 en.pdf, accessed 9 Jan 2010. Anon. Group into section? Minutes, Group for the Psychiatry of Old Age, Royal College of Psychiatrists, 1977 (typescript).
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3
Commentary on ‘In the Beginning’ by Felix Post Claire Hilton Central and North West London NHS Foundation Trust, Harrow, UK
INTRODUCTION Felix Post was probably the first dedicated old-age psychiatrist anywhere in the world. ‘In the Beginning’ is his autobiographical account of the earliest days of old-age psychiatry in Britain. Such accounts are valuable primary sources for understanding the development of the specialty. We are now reaching a point in time when our earliest pioneers like Felix Post (1913–2001) and Martin Roth (1917–2006) have died. It is important that we remember the contributions of our teachers from the past who have set the foundations for our specialty, just as Phillipe Pinel, Emil Kraepelin, Sigmund Freud and many others are celebrated for their contributions to the mental well-being of mainly younger people. This short chapter by Felix Post has been described as ‘pure Felix’. It characteristically reveals his humility and modesty, and his praise of others, attributing little achievement to himself. A brief biographical note and commentary are therefore warranted to set it in context.
‘IN THE BEGINNING’ BY THE LATE FELIX POST In 1943, after a year’s early training as one of the war-time refugees of the Maudsley Hospital, Professor Aubrey Lewis passed me on to Professor D.K. Henderson and the Royal Edinburgh Hospital for Nervous and Mental Diseases, where I initially worked in the private department. During one of his rounds, Henderson said to me: ‘Post, do you see all these old people here? Why don’t you write ‘em up?’ This I obediently did, and my article appeared in the Journal of Mental Science i . The article started by demonstrating that the admission rate of patients over 60 to the Royal Edinburgh Hospital had risen between 1901 and 1941 more steeply than the proportion of this age group in the Scottish population. Interestingly, at this early date, I had found no difficulties in the differential diagnosis of my colleagues’ and my own patients. There were 22 senile, arteriosclerotic and presenile dementia patients, 20 manic–depressive patients, 25 patients suffering from involutional or senile melancholia and 51 patients with schizophrenia. Assuming that the functional psychoses were the concern of general psychiatry, the rest of the paper dealt with the dementias and with an attempt to link the type associated with delusions and hallucinations to earlier personality characteristics. I noted that a high proportion of dementia admissions had been precipitated by terminal confusional states, and that of 111 patients admitted over the preceding four years with organic psychoses, only
23 were still occupying beds. I made the false prediction that in the future the main burden of the hospital services would be represented by the chronicity and survival of melancholic and paranoid patients. I did not anticipate that electroconvulsive therapy (ECT) and antidepressive drugs, while producing lasting recoveries in only 25% of cases, would make at least temporary discharge from inpatient care possible in most cases. Aubrey Lewis was more farsighted. He had published, with a psychiatric social workerii a paper describing the psychiatric and social features of the patients in the Tooting Bec Hospital for Senile Dementia, London, UK, and in 1946 predicted, in the Journal of Mental Science iii that ageing and senility would become a major problem of psychiatry. After army service, I consulted Lewis about possible positions and he recommended me for the post of assistant physician at the Maudsley Hospital. I flattered myself that in me Lewis had seen a future brilliant psychiatrist, but was soon to be disillusioned. Even before the Bethlem Royal and Maudsley Hospitals were united in 1948, Lewis had conceived the idea of using some of the Bethlem beds to establish a unit for patients over the age of 60. After a heated discussion with the Bethlem matron, Lewis obtained agreement for the admission of senile patients to a hospital which, like the Maudsley, had previously admitted only patients thought to be recoverable. Uncovering his batteries, he asked me to take on the development of this Geriatric Unit. Once again, I obeyed (to say without enthusiasm would be an understatement) and, right up to my retirement, I continued also to run a unit and outpatient clinic for younger adults. A report in the Bethlem Maudsley Gazette iv demonstrated that both the Bethlem staff and I had ‘caught fire’. The article started with a tribute to Professor Aubrey Lewis and his almost revolutionary idea of including experience in geriatric psychiatry within postgraduate training. The article went on to describe how patients over 60 had gradually infiltrated the Bethlem wards to emerge as a unit for 26 women and 20 men. The two wards were staffed by the same number of senior and junior nurses as the other adult wards, with two trainee psychiatrists changing every six months to other departments. There was one psychiatric social worker, later usually assisted by a trainee. The occupational therapy department had collaborated with the nursing staff to devise and carry out a daily occupational programme as well as socializing activities. The psychiatric social worker ran a weekly afternoon of handicrafts, tea and talk near the Maudsley, where throughout my tenure I conducted a weekly follow-up and
Principles and Practice of Geriatric Psychiatry, 3rd edn. Edited by Mohammed T. Abou-Saleh, Cornelius Katona and Anand Kumar 2011 John Wiley & Sons, Ltd
HISTORICAL BACKGROUND supportive clinic. The first year during which the unit had been in full swing was 1952, and it was recorded that during that year there had been 3.00 admissions to each geriatric bed compared to 3.74 admissions to each general psychiatric place. Patients who had been dementing, but whose home care was no longer possible had been excluded from admission, though not rigidly, as well as patients with recurring illnesses that had been adequately treated at the BethlemMaudsley or other hospitals. Of 133 patients, nine died, only four had to be transferred to their regional mental hospitals, seven were resettled in homes for the elderly, while 113 could be returned to family care. One year after discharge, information was successfully obtained about 121 of 124 cases. Seven patients had died, including one suicide of a woman who had discharged herself. Thirty ex-patients had to be readmitted to our or other hospitals, 35 were still outside hospital but by no means symptom-free, but 45 patients would be classified as recovered. These relatively favourable results were due to 89 patients having suffered from affective illnesses: 24 had symptoms associated with brain damage, 10 were mainly paranoid and 10 were regarded as having psychoneurosis. In spite of 4–6 weeks of conservative management 52 patients had to be given ECT. I concluded the article by pointing to research needs and by opining that with 30–40% of patients admitted to British mental hospitals being over the age of 60, training in the special problems of this age group was essential for all entrants to general psychiatry. The history of the beginning would be incomplete without a brief account of further developments. My little textbook (rightly out of print) and publications on the long-term outcome of affective, paraphrenic and schizo-affective illnesses were largely my own work, but many of the junior psychiatrists made contributions and they and clinical psychologists, as well as social workers, instigated their own researches. Many later made a name for themselves, and some became leading psychogeriatricians. Among them were Tom Arie, the late L.K. Hemsi, David Jolley, Robin Jacoby, David Kay, Kenneth Shulman and, last but certainly not least, Raymond Levy. After the Bethlem-Maudsley had accepted a district commitment and the admission of involuntary (sectioned) patients, Raymond Levy and my successor, Klaus Bergmann (not a Bethlem trainee), managed to move the Geriatric Unit to the Maudsley, so much closer to the patients’ family homes. Raymond Levy succeeded in establishing an Academic Department of Old Age Psychiatry, which has continued to conduct research into the dementias of late life, that most important subject, previously neglected on account of admission restrictions before the hospital abandoned its ivory tower to accept a district commitment. With similar developments elsewhere, psychogeriatrics became a world movement, and Sir Aubrey Lewis would be pleased.
REFERENCES i. Post F. Some problems arising from a study of mental patients over the age of sixty years. J Ment Sci 1944; 90: 554–65. ii. Lewis AJ, Goldschmidt H. Social causes of admission to a mental hospital for the aged. Sociol Rev 1943; 365: 86–98. iii. Lewis AJ. Ageing and senility: a major problem of psychiatry. J Ment Sci 1946; 92: 150–70. iv. Post F. Geriatric unit (a report on progress made, with special reference to 1952). Bethlem Maudsley Hosp Gaz 1955; 1: 270–71.
13
COMMENTARY Felix was a refugee from Nazi Germany1 . He enrolled at St Bartholomew’s Hospital in 1934, qualifying in 1939. He entered medicine in an era when it was widely assumed that older mentally ill people were ‘senile’ and therefore nothing could be done for them. Felix refers to his 1944 paper2 . He commented on his ‘false prediction’ for older people requiring long-stay care in hospital, that those with chronic functional illnesses would numerically exceed those with organic illnesses. However, he did not emphasize the real significance of his paper, his observations that ‘Old age alone does not produce mental illness’, that appropriate diagnoses can be made, and that a multidisciplinary approach is important in treating older people. The possibility of differential diagnosis from a hopeless mass of mental symptoms in old age was not widely recognized until Martin Roth’s classic paper in 19553 . Felix was a decade ahead. His conclusions were radical. Felix’s paper caught the attention of Professor Aubrey Lewis (1900–1975); he referred to it in his own landmark paper4 ; they shared a common, new and challenging belief that something could be done to treat elderly mentally ill people. Lewis had three contemporaries writing constructively on mental illness in older people. Two were relatively senior refugee psychiatrists: Willi Mayer-Gross5 and Erwin Stengel6 . The third, Felix, was earmarked by Lewis for a clinical role with older people. However, Felix had no intentions of becoming a psychiatrist, let alone one working with older people. But he was aware that refugee doctors were having difficulty in securing senior appointments, especially in traditional elitist teaching hospitals. Lewis offered him a post in 1947 at the Maudsley Hospital, London, a psychiatric teaching hospital. Henceforth, he regarded himself as owing Lewis a huge debt, and thus when Lewis asked him to be consultant on the new Geriatric Unit he could not refuse. Felix’s ambivalence to working there stemmed from the prevailing belief that nothing could be done therapeutically to help the old and mentally ill7 , despite his own published work. Lewis’s objective was to make the Bethlem-Maudsley Hospital a great centre of postgraduate psychiatric teaching and research, of which mental illness of older people would be part8 . Once established, the Geriatric Unit for functionally ill old people was sufficient for the teaching purposes envisaged by Lewis. With this objective fulfilled, Lewis and his colleagues offered Felix no further support for developing additional services for older people. ‘In the Beginning’ rightly attributes the founding of the Geriatric Unit to Lewis, but it would be inaccurate to attribute any further developments to him. The rest should be Felix’s accolade. Felix also modestly reported the outcome of treatment of his first inpatients in 1952 as ‘relatively favourable’9 . However, his results could perhaps better be described as ‘spectacular’. This is for two reasons. First, at that time most mentally ill old people requiring mental hospital admission would have been admitted to long-stay wards without any assessment, let alone treatment, for their apparent all encompassing label of ‘senility’. The expectation of any recovery was extremely low. Second, the only effective therapeutic tools were electroconvulsive therapy (ECT) and psychotherapeutic approaches; antidepressants, antipsychotics and mood stabilizers were yet to be introduced. Sadly, however, this outcome study was published in a journal with only a small circulation; had it been published in a more widely read journal it might have had a greater impact. For Felix himself, however, such results began to produce a sense of ‘therapeutic optimism’10 .
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PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRY
Felix also referred to ‘my little textbook (rightly out of print)’. This is a valid statement, but fails to reflect on the importance of the ‘little textbook’, The Clinical Psychiatry of Late Life 11 . It was the first book of its kind to emphasize an evidence-based approach to actively treating older mentally ill people. Highly readable, its philosophy remains at the foundations of good clinical practice today. It ends with the words: Sometimes, we may effect cures; frequently, we may be able to ameliorate the patient’s condition; we shall always endeavour to give him and his family sympathetic support . . . Quelquefois gu´erir; soulager souvent; consoler toujours. Why, one may ask, did so many of Felix’s junior doctors go on to become leading psychogeriatricians? It was not chance, but likely to be related to his inspiring and enthusiastic teaching. Felix’s personal career experience, moving from ambivalence to optimism to conveying his enthusiasm to others raises another contemporary lesson: we need to engage our medical students and junior staff and let them experience what can be done in order that they may carry with them the knowledge and ideals of the specialty, and possibly enter the field themselves. Felix’s widespread influence lay largely in his clinical acumen, his meticulousness, his wisdom and his teaching skills12 . Felix’s autobiographical sketch ends with the words ‘psychogeriatrics became a world movement, and Sir Aubrey Lewis would be pleased’. Lewis would undoubtedly have revelled in such lasting recognition, and hopefully the more unassuming Felix Post would also be pleased to have his legacy remembered.
REFERENCES 1. Hilton C. Felix Post (1913–2001) pioneer in the psychiatry of old age. J Med Biog 2007; 15: 31–36. 2. Post F. Some problems arising from a study of mental patients over the age of 60 years. J Ment Sci 1944; 90: 554–65. 3. Roth M. The natural history of mental disorders in old age. J Ment Sci 1955; 101: 281–301 4. Lewis AJ. Ageing and senility: a major problem of psychiatry. J Ment Sci 1946; 92: 150–70. 5. Mayer-Gross W. Electric convulsion treatment in patients over 60. J Ment Sci 1945; 91: 101–103. 6. Stengel E. A study on the symptomatology and differential diagnosis of Alzheimer’s disease and Pick’s disease. J Ment Sci 1943; 89: 1–20. 7. Post F. Interviewed by Professor Margot Jefferys for Oral History of Geriatrics as a Medical Specialty 1991: National Sound Archive F3264–F3265. 8. Lewis AJ. The education of psychiatrists. Lancet 1947; ii: 79–83. 9. Post F. Geriatric unit. Bethlem Maudsley Hosp Gaz 1955; 1: 270–71 10. Post F. Tape recording in possession of Julian Post. Unknown interviewer c. 1996. 11. Post F. The Clinical Psychiatry of Late Life. London: Pergamon Press, 1965. 12. Arie T. Remembering Felix Post. Psychiatr Bull 2002; 26: 199–200.
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Part B
Normal and Abnormal Ageing
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4
Changes in the Macrostructure and Microstructure of the Ageing Brain Natalie M. Zahr1 , Adolf Pfefferbaum2 and Edith V. Sullivan1 1 Department
of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, CA, USA 2 Neuroscience Program, SRI International, Menlo Park, CA, USA
MACROSTRUCTURAL CHANGES IN NORMAL AGEING DETECTED WITH CONVENTIONAL MRI Conventional brain structural magnetic resonance imaging (MRI) produces images of protons, with contributions primarily from water and some from fat. Tissue contrast is possible because of the fundamental differences in water content in the primary tissues of the brain: white matter consists of about 70% water, grey matter 80% and cerebrospinal fluid (CSF) 99%. Tissue contrast also depends on differences in the degree to which water is bound and differences in the local environment. By judicious choice of imaging acquisition parameters that yield high conspicuity between grey and white matter (e.g. Figure 4.1a), segmentation of brain tissue is possible. Segmentation provides the basis for volumetric and morphological quantification of brain structure1,2 . In addition to manual delineation of specific structures, methods for quantitative survey of the brain include
(a)
(b)
Figure 4.1 (a) Structural magnetic resonance imaging (spoiled gradient recalled, SPGR), and (b) diffusion tensor imaging (fractional anisotropy, FA) images from a young (32 year old) and an elderly (73 year old) male volunteer. SPGR images exemplify those that yield conspicuity between grey and white matter permitting brain tissue segmentation. Fractional anisotropy images facilitate fibre tracking
voxel-based morphometry, as is widely used with spatial parametric mapping (SPM)3,4 , parcellation2,5 and deformation morphometry6 – 8 . The achievement of quantitative analysis was an essential step for rendering MR images useful in the quest for reliable identification of age-related macrostructural change. In vivo structural MRI reveals age-related increases in the volume of CSF-filled spaces primarily at the expense of cortical grey matter (cross-sectional9 – 14 , longitudinal15 – 19 ). Despite evidence for widespread thinning of the cerebral cortex as a feature of normal ageing16,20,21 , specific grey matter structures of the brain exhibit differential patterns of ageing. A preponderance of data indicates an excessive vulnerability of the frontal lobes, and in particular the prefrontal cortex, as documented cross-sectionally22 – 25 . Other grey matter structures demonstrating cross-sectional decline in volume with age include, but are not limited to, segments of the temporal20,25 and parietal cortices20 , thalamus12,26 , and cerebellum11,21,27 . Longitudinal studies, although less frequently reported, support cross-sectional results by revealing disproportionate effects of age on frontal grey matter regions15,17,28 , entorhinal28,29 , temporal17,28 , parietal17 cortices, and cerebellum21 . Some30 , but not all27,31 MRI studies of subcortical structures report little shrinkage of basal ganglia structures. Similarly, although some reports are equivocal16,28,32 , it is generally accepted that hippocampal volume shrinks little with age20,33,34 . That hippocampal volume shrinkage is not a reliable marker of healthy ageing makes it a robust marker of age-related diseases affecting this structure, notably, Alzheimer’s disease. The relevance of structural MRI findings to age-related decline in function is underscored by correlations with selective behaviours. For example, smaller prefrontal volume predicts poorer performance on the Wisconsin Card Sorting test35 and other tasks involving inhibitory control36,37 . Deficits in the working memory that occur in normal ageing correlate with frontal system volume38 , whereas episodic memory deficits that occur in Alzheimer’s disease correlate with medial temporal lobe/hippocampal volume39 – 41 . Such findings support a double dissociation between normal ageing and Alzheimer’s disease: frontal brain volume reductions and executive dysfunction mark normal ageing, whereas volume reductions in the medial temporal lobe/hippocampus and the corresponding memory deficits indicate Alzheimer’s pathology20,42,43 .
Principles and Practice of Geriatric Psychiatry, 3rd edn. Edited by Mohammed T. Abou-Saleh, Cornelius Katona and Anand Kumar 2011 John Wiley & Sons, Ltd
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PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRY
MICROSTRUCTURAL CHANGES IN NORMAL AGEING DETECTED WITH DTI Whole-brain white matter volume shrinkage is small, estimated at no more than 2% per decade27 (but see 31,44 ). Yet postmortem investigations, in contrast to macrostructural approaches, have provided fruitful leads to age-related changes in white matter by revealing microstructural white matter compromise45 including degradation of microtubules, myelin and axons46 – 48 . In vivo, white matter microstructure is detectable with DTI, which has successfully revealed evidence of regional white matter disruption in normal ageing even in regions appearing normal on bulk volume imaging.
Quantification of DTI Data Water molecules in the brain are in constant Brownian motion. Although movement of water protons affects conventional structural imaging to some degree, DTI allows quantification of this microscopic movement within each voxel, providing a depiction of local water molecular movement in terms of the preferred orientation of the motion. Along a white matter fibre, the path of a water molecule is constrained and this movement is called ‘anisotropic’, because diffusion along the long axis of a fibre (axial diffusion) is greater than diffusion across the fibre (radial diffusion49 ). Conversely, regions with few or no constraints imposed by physical boundaries such as CSF in the ventricles allow water movement to be random in every direction; this is therefore ‘isotropic’. Disruption of white matter microstructure detectable with DTI can reflect compromise of cytoskeletal structure, myelin or axon density50,51 . DTI quantification requires computation of a tensor, a mathematical description of a three-dimensional ellipsoid depicting the magnitude and orientation of diffusion in individual voxels. The tensor is associated three eigenvalues, with three corresponding orientational vectors (eigenvectors, λ1 , λ2 , λ3 ), describing the diffusion ellipsoid by its major axes. The eigenvalue average, or trace, reflects the magnitude of diffusion, referred to as mean diffusivity or the apparent diffusion coefficient. The extent to which one eigenvalue, λ1 , dominates the other two, λ2 and λ3 , determines the degree of anisotropy, that is, the degree of orientational preference within a voxel, typically measured as fractional anisotropy, ranging between 0 and 1 on a normalized scale (Figure 4.1b52 ). The largest eigenvalue, λ1 , is the longitudinal or axial diffusivity, λL , and reflects axonal integrity, whereas λ2 and λ3 quantify transverse or radial diffusivity, λT = (λ2 + λ3 )/2, and reflect myelin integrity49,53 . For both clinical and research studies, most DTI data sets are reduced to an anisotropy image and a diffusivity image. (For more information about DTI, see54 .)
Regional Quantification of DTI Data A variety of approaches have been developed for quantification of DTI data; each has strengths and weaknesses that should be considered when critically evaluating published reports. Approaches for regional quantification of the DTI metrics of anisotropy and diffusivity include manually placing small, geometric samples (cubes, ovals, circles) onto selective white matter bundles, manually identifying anatomically based regions of interest (ROI, e.g. midsagittal corpus callosum), application of whole-brain analysis using SPM or other voxel-based morphometric methods, or tract-based spatial statistics (TBSS55 ). Geometric ROIs have the advantage of yielding rarefied
samples of white matter with minimal effects from partial voluming (i.e. inclusion of grey matter, CSF or both) but the potential disadvantage of under-representing the condition of the full extent of the fibre system under study. Manual identification of the entire fibre tract has the advantage of providing an anatomically based sample of the target fibre with the possibility of examining subdivisions for regional variation; a disadvantage can be its susceptibility to partial voluming artefact because of the extended region sampled56 . Voxel-based morphometry is attractive because it provides an automated, wholebrain survey of fractional anisotropy or diffusivity, but more often than not, has the under-appreciated cost of inadequate registration6 . Such misregistration can disproportionately bias results and conclusions drawn from data, especially of the elderly57 , who have dilated CSF-filled spaces invading targeted white matter samples58 . TBSS is another survey approach that does not actually track fibres but is used to quantify the whole-brain fractional anisotropy skeleton59 .
AGEING EFFECTS ON DTI METRICS With advancing age and senescence, a consensus maintains a decline in fractional anisotropy in brain white matter56,60 – 65 (but see 66,67 ). Furthermore, consistent evidence supports an anterior–posterior gradient of fractional anisotropy decline with age57,58,60,61,65,68 – 74 that has been confirmed in a monkey model of ageing75 . TBSS likewise substantiates an anterior–posterior gradient, namely by identifying lower fractional anisotropy values in the frontal, parietal and temporal lobes, corpus callosum (particularly the genu and body) and the internal capsule76 . In complement to white matter fractional anisotropy decline in ageing, diffusivity in white matter increases58,65,67,77 – 80 . As with fractional anisotropy, profile analysis reveals that the primary locus of the age effect is in anterior white matter80 . This pattern of agerelated decline of fractional anisotropy and increase in diffusivity mirrors postmortem observations with predominant age-related findings in anterior white matter systems45,81 .
QUANTITATIVE FIBRE TRACKING IN AGEING The degree to which the diffusion orientation of a voxel is similar to its neighbours, or in other words, coherence of diffusivity measures between voxels82,83 , serves the conceptual basis for quantitative fibre tracking55,84 – 87 . Connectivity and coherence between different brain regions on vector and fibre tracking maps is readily apparent on visual inspection88 . Methods for quantitative analysis of structural connectivity of white matter include fibre-tract trajectories89 – 91 and maps of the degree of ‘alignment’ among neighbouring vectors, on a voxel-to-voxel basis, resulting in a measure of intervoxel coherence82 . Advantages of quantitative fibre tracking over focal ROI analysis include the ability to measure the entire extent of a fibre tract and to characterize its integrity along its full extent. Quantitative fibre tracking confirms focal DTI measures of an anterior-to-posterior pattern of disruption of white matter integrity92,93 as, for example, the elderly have lower fractional anisotropy and higher diffusivity than the young in anterior but not posterior sectors of the fibres coursing through the corpus callosum (Figure 4.2)94 – 96 . Recent work also supports a superior–inferior gradient of ageing effects on white matter (Figure 4.3)97 – 99 , whereas pontocerebellar and cerebellar hemisphere white matter tracts are relatively preserved97 .
NORMAL AND ABNORMAL AGEING
l
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Figure 4.2 Top sagittal image: Example of fibre tracking of the corpus callosum of a 23-year-old healthy woman. The colours represent six different fibre bundles based on previously described divisions148 identified with fibre tracking based on diffusion tensor imaging (DTI)-derived fractional anisotropy. From anterior (far left) to posterior (far right), the bundles are deemed prefrontal, premotor, precentral, postcentral, posterior parietal, and temporal-occipital. Bottom data figures: Mean ± SE of the six callosal sectors for the young and elderly groups at MRI sessions two years apart of the four principal metrics of DTI: fractional anisotropy, apparent diffusion coefficient (ADC), λ1 and λt . The elderly group had lower fractional anisotropy and higher diffusivity than the young group at both scanning sessions, and the group differences were greatest in anterior sectors. Reproduced with permission from Sullivan et al .105
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Figure 4.3 Images: Fibre tracts were identified on the group-average fractional anisotropy image in common space. (a) Sagittal (top) and axial (bottom) views of the genu, splenium and fornix. (b) Sagittal (top) and coronal (bottom) views of the uncinate fasciculus. (c) Sagittal (top) view of the cingulum (superior, posterior, inferior) and inferior longitudinal fasciculus (bottom). Bar graphs: Mean ± SD for fractional anisotropy, apparent diffusion coefficient (ADC), λ1 and λt for young (grey) and elderly (white) subjects for each fibre bundle. *P ≤ 0.05t -test. Modified from Zahr et al .99
NORMAL AND ABNORMAL AGEING
LONGITUDINAL STUDIES OF AGEING BRAIN MICROSTRUCTURE Longitudinal studies of normal, healthy men and women across the adult age range document normative age-related, DTI-detectable changes in brain white matter that are requisite for interpreting DTI data from individuals with neuropsychiatric disorders and other conditions affecting the brain. However, longitudinal studies have their own problems with respect to measurement reliability within and across research centres, selective attrition, and hardware and software system modifications and drift100 . For example, a study of five normal adults imaged five times each resulted in 5% across-subject variation and a mean variation of 2.3 ± 1.2 SD% in diffusivity78 . Another study measured the reliability of global and regional fractional anisotropy and diffusivity measurements in ten healthy young adults, imaged three times on two different 1.5-T scanners made by the same manufacturer101 . When reliability was measured on a voxel-by-voxel basis or on a slice-by-slice basis, fractional anisotropy and diffusivity values were equivalently and significantly higher within than across scanners. In addition to reliability of a common measurement approach, substantial differences can arise when different analysis schemes are applied to the same data set102 . Longitudinal DTI studies of healthy ageing are only now emerging. The few studies reporting longitudinal results in normal ageing do so secondarily, in that the target study groups were individuals with neurological conditions, including head injury103 and amyotrophic lateral sclerosis104 ; in neither control group were age-related declines in fractional anisotropy or increases in diffusivity detected. One small prospective study followed eight young and eight elderly individuals over two years105 but found no evidence of change in any of the six sectors of the corpus callosum examined; instead, the measurement was highly reliable across the interval (see Figure 4.2).
BRAIN WHITE MATTER STRUCTURE– FUNCTION RELATIONSHIPS The functional ramifications of the DTI metrics have been regularly verified with observations of correlations between regionally specific low fractional anisotropy or high diffusivity and poor cognitive61,62,71 – 73,106,107 or motor68 test performance in humans and also a monkey model of ageing75 . Lower whole-brain fractional anisotropy and higher mean diffusivity correlated with working memory performance106,108 . The alternating finger-tapping task, a test of interhemispheric information transfer, revealed a relationship between splenium and parietal pericallosal white matter fractional anisotropy and finger-tapping output that was selective to the alternating condition, requiring interhemispheric motor coordination, and not unimanual conditions, free of transcallosal information exchange68 . Task switching61,109 and lower scores on tests of executive functions63,109 correlated with low fractional anisotropy and greater diffusivity in anterior brain regions; lower verbal fluency scores correlated with lower fractional anisotropy in central samples of white matter61 . Functional correlates of regional fibre tracking are also emerging. Correlations between fibre tracking quantification and the Stroop color-word reading were noted94 . A large, multifactorial battery of neuropsychological tests reduced to three factor scores revealed that problem solving and working memory factor scores correlated with indices of callosal genu and fornix integrity, whereas the motor factor score correlated with a widespread set of fibre systems, likely
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reflecting the multiple brain loci required to execute the tasks, which included speed, dexterity and choice reaction time (Figure 4.4)99 .
LIMITATIONS OF DTI DTI studies indicate widely varying fractional anisotropy across brain regions, with lower anisotropy and higher in diffusivity in older than younger healthy adults, that is prominent in the anterior supratentorial white matter but minimal to none in posterior cortical and corticospinal tracts. A caveat to this generalization is that selective deletion of uniformly orientated white matter fibres from a tissue sample of crossing fibres, as can occur with Wallerian degeneration, can cause abnormally high anisotropy110 . Therefore, interpretation of fractional anisotropy results requires guidance by knowledge of the underlying regional architecture, especially white matter111 and supplemented with non-human primate studies, affording the opportunity for in vivo examination and postmortem verification of imaging results (cf.88 ). Furthermore, the diameters of axons, for example in the corpus callosum ranging from 0.4 to 5 µm, with most less than 1 µm, means that a cross-section of the genu of the human corpus callosum contains approximately 400 000 fibres per mm2 and a single DTI voxel using relatively high resolution (2 × 2 × 2 mm3 ) for current standards could contain 1.6 million fibres in a cross-section112 . Consequently, caution must be used when interpreting the anatomical meaning of observations made with radiological measures, which are coarse on the size scale of the underlying fibres. Finally, the diffusion-weighted signal can also be influenced by iron accumulation with age, and the resulting effect is different among deep grey matter structures and white matter and needs to be considered, especially when using DTI to characterize structures known to accumulate iron (in vivo 113 , postmortem114 ) or in conditions, such as stroke, that produce high ferritin deposition (cf.115 ).
OTHER STRUCTURAL MAGNETIC RESONANCE OBSERVATIONS IN AGEING Convergent postmortem114 and in vivo data indicate that deep grey matter brain structures accumulate ferritin at different rates throughout adult ageing113,116,117 . Abnormal iron accumulation has been reported in neurological conditions involving the basal ganglia, including Parkinson’s disease, multiple sclerosis and Huntington’s disease (reviewed in: 113,118 – 122 ), and suggests that iron burden contributes to age- and disease-related functional decline123,124 . Iron can be measured in vivo with MR imaging because of iron’s effect on signal intensity, causing signal darkening on T2* and T2-weighted images that is greater with increasing magnetic field strength. By estimating the transverse relaxivity increase across field strengths, the MR field-dependent relaxivity increase (FDRI) can be calculated113,125,126 . For example, acquisition of spin-echo data with a constant TR and multiple echoes at 1.5-T and 3.0-T allows the computation of R2 (the inverse of T2) at each field strength with the difference between R2s divided by the field strength difference producing FDRI in units of s−1 /T (Figure 4.5a). In addition to affecting relaxivity, local iron influences MR gradient-echo image phase, which forms the basis for another method for iron quantification, susceptibility-weighted imaging (SWI) (Figure 4.5b)127 . The paramagnetic properties of tissue ferritin cause local field inhomogeneity that can also be quantified by examining the phase of the computed spins. The ferromagnetic
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Figure 4.4 Correlations (Spearman rank and Bonferroni corrected) between a working memory domain isolated using principal component analysis and diffusion tensor imaging (DTI) metrics (fractional anisotropy and apparent diffusion coefficient) by tract. Modified from Zahr et al .99
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Figure 4.5 Group averages for 11 younger (mean= 24 years old, 5 men, 6 women) and 12 older (mean= 74 years old, 6 men, 6 women) participants for (a) field-dependent relaxivity increase (FDRI) and (b) susceptibility-weighted imaging (SWI) techniques for measuring brain iron. Greater iron concentration yields higher (brighter) FDRI signal but lower (darker) SWI signal. Modified from Pfefferbaum et al .126
property of iron causes protons to accrue more negative phase in iron-rich tissue. At optimal acquisition parameters, the more iron in a voxel, the lower will be the measured phase127 . FDRI and SWI document increasing iron deposition with age in deep brain structures such as the caudate and putamen, globus pallidus, red nucleus, substantia nigra and thalamus113,119,126,128 . In a recent comparison study between FDRI and SWI, both methods detected high globus pallidus iron concentration independent of age and significantly greater iron in putamen with advancing age126 . Further senescent changes in brain tissue composition and emblematic of tissue degradation are the increases in presence and volume of white matter hyperintensities (WMHIs) (e.g. 129 – 131 ), typically visible in T2-weighted and fluid-attenuated inversion recovery (FLAIR, Figure 4.6) images. WMHIs are associated, for example, with hypertension, stroke, traumatic brain injury and respiratory dysfunction132 – 134 . The current controversy regarding WMHIs aetiology is whether a common pathophysiological mechanism underlies the formation of periventricular and deep white matter lesions134 – 136 . It is thought that demyelination or ependymal lining damage commonly occurs periventricularly, whereas rarefication of myelin or cavitations from fibre loss, concomitant of ischaemic damage or arteriosclerosis, commonly occurs in deep white matter130 . Depending on the location of WMHIs, different types of functional decline can ensue136,137 .
NORMAL AND ABNORMAL AGEING
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ACKNOWLEDGEMENTS This work was supported by NIH grants AG017919, AA017168, and AA005965.
REFERENCES
Figure 4.6 Coronal image from a healthy elderly adult volunteer (72 years old) displaying white matter hyperintensities in deep (closed arrows) and periventricular (open arrow) regions of the brain
CONCLUSION The twentieth century has seen a dramatic increase in life expectancy in developed countries. Estimates from the Health and Retirement Study, sponsored by the US National Institute on Ageing, indicate that ∼10% of individuals aged 70 and older in the United States suffer moderate to severe cognitive impairment that rises to ∼20% by age 85 years138 . Therefore, expanding longevity coupled with declining CNS function will dictate the need for continued development of clinically practical and sensitive imaging modalities to assist in the differential diagnosis of age-related diseases. Advances in neuroradiology have contributed to the neuroscience of normal ageing and to characterizing morphological and tissue changes that occur in the brain with age. Among these is the identification of previously underappreciated occurrence of decline in white matter integrity. The in vivo interrogation of the brain has also highlighted the dramatic, involutional brain tissue shrinkage and replacement with CSF, less apparent at the autopsy table as the brain collapses in on itself when removed from the skull139 . Finally, a principal aim of this paper was to emphasize neuroradiological concomitants of apparent normal ageing, thereby providing an essential context in which to interpret radiological evidence for neurodegenerative diseases and other conditions of brain insult. Careful history taking and clinical description of presumed healthy men and women have proved essential in identifying factors that underlie departure from normality28 or are categorized as ‘normal variants’140 . Factors increasing in prevalence with age and affecting brain tissue and potentially function include hypertension141 , cerebrovascular disease135,142 , and iron deposition113 . DTI can be more sensitive than conventional MRI for detection of subtle and perhaps prodromal changes in tissue that occur with age (cf. 126,143,144 ), including those characteristic of stroke145 – 147 . Use and quantification of tractography may also enable monitoring white matter fibre regrowth148 following trauma, disease or recovery from alcohol and drug dependence and to test models of white matter recovery in normal ageing, trauma and disease.
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85. Fillard P, Gerig G. Analysis tool for diffusion tensor MRI. In Proceedings of Medical Image Computing and Computerassisted Intervention, Lecture Notes in Computer Science. SaintMalo, France: Springer, 2003. 86. Le Bihan D. The ‘wet mind’: water and functional neuroimaging. Phys Med Biol 2007; 52: R57–90. 87. Mori S, Wakana S, Nagae-Poetscher LM, Van Zijl PMC. An Atlas of Human White Matter. Amsterdam: Elsevier, 2005. 88. Schmahmann JD, Pandya DN, Wang R et al. Association fibre pathways of the brain: parallel observations from diffusion spectrum imaging and autoradiography. Brain 2007; 130: 630–53. 89. Masutani Y, Aoki S, Abe O, Hayashi N, Otomo K. MR diffusion tensor imaging: recent advance and new techniques for diffusion tensor visualization. Eur J Radiol 2003; 46: 53–66. 90. Basser PJ, Pierpaoli C. A simplified method to measure the diffusion tensor from seven MR images. Magn Reson Med 1998; 39: 928–34. 91. Mori S, van Zijl PC. Fiber tracking: principles and strategies – a technical review. NMR Biomed 2002; 15: 468–80. 92. Davis SW, Dennis NA, Buchler NG, White LE, Madden DJ, Cabeza R. Assessing the effects of age on long white matter tracts using diffusion tensor tractography. NeuroImage 2009; 46: 530–41. 93. Falangola MF, Jensen JH, Babb JS et al. Age-related nonGaussian diffusion patterns in the prefrontal brain. J Magn Reson Imaging 2008; 28: 1345–50. 94. Sullivan EV, Adalsteinsson E, Pfefferbaum A. Selective agerelated degradation of anterior callosal fiber bundles quantified in vivo with fiber tracking. Cereb Cortex 2006; 16: 1030–29. 95. Pfefferbaum A, Rosenbloom MJ, Adalsteinsson E, Sullivan EV. Diffusion tensor imaging with quantitative fibre tracking in HIV infection and alcoholism comorbidity: Synergistic white matter damage. Brain 2007; 130: 48–64. 96. Hasan KM, Ewing-Cobbs L, Kramer LA, Fletcher JM, Narayana PA. Diffusion tensor quantification of the macrostructure and microstructure of human midsagittal corpus callosum across the lifespan. NMR Biomed 2008; 21: 1094–101. 97. Sullivan EV, Rohlfing T, Pfefferbaum A. Quantitative fiber tracking of lateral and interhemispheric white matter systems in normal ageing: Relations to timed performance. Neurobiol Aging 2010; 31: 464–81. 98. Stadlbauer A, Salomonowitz E, Strunk G, Hammen T, Ganslandt O. Age-related degradation in the central nervous system: assessment with diffusion-tensor imaging and quantitative fiber tracking. Radiology 2008; 247: 179–88. 99. Zahr NM, Rohlfing T, Pfefferbaum A, Sullivan EV. Problem solving, working memory, and motor correlates of association and commissural fiber bundles in normal ageing: a quantitative fiber tracking study. NeuroImage 2009; 44: 1050–62. 100. Birren JE, Schaie KW. Handbook of the Psychology of Aging, 5th edn. San Diego: Academic Press, 2001. 101. Pfefferbaum A, Adalsteinsson E, Sullivan EV. Replicability of diffusion tensor imaging measurements of fractional anisotropy and trace in brain. J Magn Reson Imaging 2003; 18: 427–33. 102. Jones DK, Symms MR, Cercignani M, Howard RJ. The effect of filter size on VBM analyses of DT-MRI data. Neuroimage 2005; 26: 546–54. 103. Sidaros A, Engberg AW, Sidaros K et al. Diffusion tensor imaging during recovery from severe traumatic brain injury and
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NORMAL AND ABNORMAL AGEING 122. Schenck JF, Zimmerman EA, Li Z et al. High-field magnetic resonance imaging of brain iron in Alzheimer disease. Top Magn Reson Imaging 2006; 17: 41–50. 123. Bartzokis G, Lu PH, Tingus K et al. Lifespan trajectory of myelin integrity and maximum motor speed. Neurobiol Aging 2009 (in press). 124. Sullivan EV, Adalsteinsson E, Rohlfing T, Pfefferbaum A. Relevance of iron deposition in deep gray matter brain structures to cognitive and motor performance in healthy elderly men and women: exploratory findings. Brain Imaging Behav 2009 (in press). 125. Bartzokis G, Aravagiri M, Oldendorf WH, Mintz J, Marder SR. Field dependent transverse relaxation rate increase may be a specific measure of tissue iron stores. Magn Resonance Med 1993; 29: 459–64. 126. Pfefferbaum A, Adalsteinsson E, Rohlfing T, Sullivan EV. MRI estimates of brain iron concentration in normal ageing: Comparison of field-dependent (FDRI) and phase (SWI) methods. NeuroImage 2009; 47: 493–500. 127. Haacke EM, Xu Y, Cheng YC, Reichenbach JR. Susceptibility weighted imaging (SWI). Magn Reson Med 2004; 52: 612–18. 128. Harder SL, Hopp KM, Ward H, Neglio H, Gitlin J, Kido D. Mineralization of the deep gray matter with age: a retrospective review with susceptibility-weighted MR imaging. AJNR Am J Neuroradiol 2008; 29: 176–83. 129. Malloy P, Correia S, Stebbins G, Laidlaw DH. Neuroimaging of white matter in ageing and dementia. Clin Neuropsychol 2007; 21: 73–109. 130. Fazekas F, Kleinert R, Offenbacher H et al. Pathologic correlates of incidental MRI white matter signal hyperintensities. Neurology 1993; 43: 1683–89. 131. Cahn DA, Malloy PF, Salloway S et al. Subcortical hyperintensities on MRI and activities of daily living in geriatric depression. J Neuropsychiatry Clin Neurosci 1996; 8: 404–11. 132. Liao D, Cooper L, Cai J et al. The prevalence and severity of white matter lesions, their relationship with age, ethnicity, gender, and cardiovascular disease risk factors: the ARIC Study. Neuroepidemiology 1997; 16: 149–62. 133. Kuller LH, Longstreth WT, Jr., Arnold AM, Bernick C, Bryan RN, Beauchamp NJ, Jr. White matter hyperintensity on cranial magnetic resonance imaging: a predictor of stroke. Stroke 2004; 35: 1821–25. 134. Holland CM, Smith EE, Csapo I et al. Spatial distribution of white-matter hyperintensities in Alzheimer disease, cerebral amyloid angiopathy, and healthy ageing. Stroke 2008; 39: 1127–33. 135. DeCarli C, Fletcher E, Ramey V, Harvey D, Jagust WJ. Anatomical mapping of white matter hyperintensities (WMH): exploring the relationships between periventricular WMH, deep WMH, and total WMH burden. Stroke 2005; 36: 50–55.
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136. Kim KW, MacFall JR, Payne ME. Classification of white matter lesions on magnetic resonance imaging in elderly persons. Biol Psychiatry 2008; 64: 273–80. 137. Kochunov P, Ramage AE, Lancaster JL et al. Loss of cerebral white matter structural integrity tracks the gray matter metabolic decline in normal ageing. NeuroImage 2009; 45: 17–28. 138. National Institute on Aging. Growing Older in America: The Health & Retirement Study, 2009. At www.nia.nih.gov/NR /exeres/C80ADCEA-DE6E-4EF0-8D75-FD32AAE9BE6A.html, accessed Feb 2010. 139. Pfefferbaum A, Sullivan EV, Adalsteinsson E, Garrick T, Harper C. Postmortem MR imaging of formalin-fixed human brain. Neuroimage 2004; 21: 1585–95. 140. DeCarli C, Massaro J, Harvey D et al. Measures of brain morphology and infarction in the Framingham heart study: establishing what is normal. Neurobiol Aging 2005; 26: 491–510. 141. Brickman AM, Schupf N, Manly JJ et al. Brain morphology in older African Americans, Caribbean Hispanics, and whites from northern Manhattan. Arch Neurol 2008; 65: 1053–61. 142. Nordahl CW, Ranganath C, Yonelinas AP, Decarli C, Fletcher E, Jagust WJ. White matter changes compromise prefrontal cortex function in healthy elderly individuals. J Cogn Neurosci 2006; 18: 418–29. 143. Tullberg M, Fletcher E, DeCarli C et al. White matter lesions impair frontal lobe function regardless of their location. Neurology 2004; 63: 246–53. 144. O’Brien JT, Erkinjuntti T, Reisberg B et al. Vascular cognitive impairment. Lancet Neurol 2003; 2: 89–98. 145. Moseley ME, Kucharczyk J, Mintorovitch J et al. Diffusionweighted MR imaging of acute stroke: correlation with T2weighted and magnetic susceptibility-enhanced MR imaging in cats. Am J Neuroradiol 1990; 11: 423–29. 146. Moseley ME, Mintorovitch J, Cohen Y et al. Early detection of ischemic injury: comparison of spectroscopy, diffusion-, T2-, and magnetic susceptibility-weighted MRI in cats. Acta Neurochir Suppl 1990; 51: 207–209. 147. Peters A, Sethares C. Is there remyelination during ageing of the primate central nervous system? J Comp Neurol 2003; 460: 238–54. 148. Pandya DN, Seltzer B. The topography of commissural fibers. In Lepore F, Ptito M, Jasper HH (eds), Two Hemispheres – One Brain: Functions of the Corpus Callosum. New York: Alan R. Liss, 1986, 47–74.
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Functional Imaging of the Ageing Brain Robert Perneczky, Christian Sorg and Hans F¨orstl Department of Psychiatry and Psychotherapy, Klinikum rechts der Isar, Technische Universit¨at M¨unchen, M¨unchen, Germany
INTRODUCTION Modern imaging techniques such as functional magnetic resonance imaging (fMRI), positron emission tomography (PET) and single photon emission tomography (SPECT) provide the groundwork to test mechanistic hypotheses derived from basic neuroscience studies in healthy individuals and patients with neurological and psychiatric disorders. Apart from these scientific applications, functional imaging studies can also provide important diagnostic information in the field of geriatric psychiatry. Therefore, functional imaging scans are recommended by diagnostic guidelines to resolve certain differential diagnostic issues1 , and costs are also reimbursed for these special cases in selected countries (e.g. Medicare Coverage Criteria for FDG-PET for Alzheimer’s disease, http://nps.cardinal.com/nps/PETFoundations/documents/ PETADCovFinal.pdf). In addition to its benefits for the diagnosis and differential diagnosis of neurological and psychiatric disorders, functional brain imaging has also been shown to increase the confidence of experts in their clinical diagnosis. For example, Foster et al.2 reported that visual rating of 18 F-fluoro-2-deoxy-glucose (FDG) PET scans after a short training period was more reliable and accurate in distinguishing Alzheimer’s disease from frontotemporal dementia (FTD) than clinical assessment on its own. This was particularly true when the raters were uncertain with their clinical diagnosis. Hence, FDG PET is able to add important diagnostic information that appropriately improves diagnostic confidence. Biomarkers including functional imaging are also gaining importance for the evaluation and monitoring of treatment effects. Modern, sensitive techniques are able to detect subtle brain functional changes resulting from therapeutic interventions, even if the therapeutic effect is not immediately mirrored by clinical improvement. This could lead to the identification of treatment responders in very early treatment phases3 or before the actual treatment period has even started. Furthermore, for some potentially preventive treatments to have their greatest impact, patients need to be identified at the presymptomatic stage. This means that individuals with an increased risk for a certain disease, but who do not yet show any clinical signs, need to be identified. Persons at risk for Alzheimer’s disease, for example, can already be identified on the basis of brain metabolic deficits in their FDG PET scans before first symptoms, such as forgetfulness, appear4 . This chapter provides an overview of a selection of functional imaging techniques and brain functional changes associated with
ageing, some prevalent neurodegenerative and psychiatric disorders, and those due to treatment. Important clinical aspects and future research perspectives will be discussed.
FUNCTIONAL IMAGING TECHNIQUES Functional neuroimaging is broadly defined as techniques that provide measures of brain activity. Commonly used techniques are electroencephalography (EEG), magnetoencephalography (MEG), PET, SPECT and fMRI. Here we focus on PET and fMRI, which primarily aim at the regional mapping of mental processes. These techniques measure metabolic and haemodynamic brain processes closely linked with neuronal activity. PET and fMRI allow both the detection of regional activity changes in response to experimentally presented stimuli or cognitive tasks and the detection of synchronous co-activity changes across brain regions in response on stimuli or during rest. In this section we review the biological basis of functional neuroimaging signals, then we describe the physics of PET and fMRI signals, and finally we discuss two basic principles underlying functional neuroimaging data analysis: functional specialization and functional integration. Behaviourally evoked changes in blood flow are at the heart of functional neuroimaging5 . Blood flow changes reflect metabolic changes, which in turn reflect changes in neuronal activity. From a metabolic point of view neuronal activity is dominated by transmitter recycling. Eighty per cent of brain energy is used for glutamate recycling. Central to glutamate recycling are aerobic glycolysis and oxidative phosphorylation. These activity-dependent processes with their main substrates H2 O, O2 and glucose provide the basis for15 O-H2 O-PET, FDG PET, and blood oxygen level-dependent (BOLD) fMRI. Oxygen-15 and fluorine-18 are isotopes with short half-lives that are introduced into the body incorporated into H2 O and glucose. As the tracers decay, emitted gamma rays are detected by the PET scanner and used for image construction. The spatial resolution is about 1.5 cm and the temporal resolution is about 60 s; both values strongly influence the experimental design of neurocognitive paradigms. The fundamental signal for BOLD fMRI comes from hydrogen atoms mainly bonded to H2 O within the brain. In the presence of a static magnetic field, these hydrogen atoms absorb energy that is applied at a characteristic radio frequency. After radiofrequency excitation,
Principles and Practice of Geriatric Psychiatry, 3rd edn. Edited by Mohammed T. Abou-Saleh, Cornelius Katona and Anand Kumar 2011 John Wiley & Sons, Ltd
NORMAL AND ABNORMAL AGEING hydrogen atoms emit energy at the same radiofrequency until they gradually return to their equilibrium state (resonance phenomenon). The MRI scanner measures the emitted radiofrequency energy. The measured radiofrequency signal decays over time, influenced by distinct factors, including the presence of inhomogeneities in the magnetic field. BOLD fMRI techniques are designed to measure primarily changes of inhomogeneity within a small volume of tissue that result from changes in blood oxygenation. Deoxy- and oxyhaemoglobin (Hb-CO2 , Hb-O2 ) have different magnetic properties; Hb-CO2 is paramagnetic and introduces an inhomogeneity into the nearby magnetic field, whereas Hb-O2 is weakly diamagnetic with little effect. Hence, an increase in the concentration of Hb-CO2 causes a decrease in image intensity, and a decrease in Hb-CO2 causes an increase in image intensity (BOLD effect). The spatial resolution of BOLD fMRI is about 0.5 cm and temporal resolution about 1–4 seconds. There are two key topics in the analysis of functional imaging data, reflecting the long-standing debate in neuroscience about functional specialization versus functional integration in the brain6 . The first is brain ‘mapping’, where three-dimensional images of neuronal activation are generated showing which parts of the brain respond to a given sensory stimulus or cognitive task. This is also known as the study of functional specialization and generally proceeds using some form of statistical parametric mapping (SPM) based on a voxel-wise analysis. A classic example here is the identification of human V4 and V5, the areas specialized for the processing of colour and motion. The second topic is ‘functional integration’, where models are used to analyse how different brain areas interact. A classic example is the use of models to find increased connectivity between dorsal and ventral visual streams after subjects learn object–place associations. A large number of statistical techniques are used to detect interregional connectivity (e.g. independent component analysis, support vector machine, dynamic causal modelling).
AGE-RELATED FUNCTIONAL CHANGES Brain Functional Decline ‘Normal ageing’ is associated with numerous biological deteriorations in the human body, which also include brain functional changes. However, ‘normal ageing’ is a rather fuzzy concept and it is sometimes difficult to separate age-related and disease-related brain changes. All the same, with age the brain undergoes both structural and functional changes that underlie subjective complaints. The pre-frontal cortex shows the most prominent functional deterioration in most studies, whereas other regions including the anterior hippocampus, the thalamus and the posterior cingulate cortex are affected to a much lesser extent7 . These results support the theory that the first areas to emerge phylo- and ontogenetically are the most resistant to age effects and the last to emerge are the most vulnerable. Furthermore, the relative functional preservation of brain structures during ‘normal ageing’ that are affected early in Alzheimer’s disease, such as the hippocampus and the posterior cingulate cortex8 , seems to mark the parting of the ways between ageing and brain disease. This is also supported by the finding that cognitively normal elderly individuals with a pathological brain metabolic pattern are more likely to experience memory decline9 and are at elevated risk of developing symptoms of Alzheimer’s disease10 . Also in line with these findings, Alzheimer’s disease-like brain functional patterns are also found in cognitively normal elderly individuals with an increased genetic risk for Alzheimer’s disease (i.e. carriers of the
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apolipoprotein E allele ε4 (APOE4 )11 ). Alzheimer’s disease-like changes are already present at even younger ages in pre-symptomatic individuals from families with known early-onset autosomal dominant Alzheimer’s disease-carrying mutations in the PRESENILIN1 gene12 . Interestingly, a maternal history of Alzheimer’s disease also predisposes cognitively normal individuals to progressive metabolic deficits in Alzheimer’s disease-vulnerable brain regions, which may be related to a higher risk of developing the disease4 . Although the exact causes of these abnormalities are not yet known, these results suggest the involvement of maternally inherited predisposition to brain metabolic failure, possibly connected to mitochondrial DNA. The facts that mitochondrial DNA is entirely maternally inherited in humans, and diseases associated with mitochondrial DNA mutations often present as sporadic disorders, support this hypothesis.
Adaptation and Compensation Age- and disease-related changes are not only associated with functional deterioration but also with counteractive measures. Accessory neural networks are activated to solve increasingly difficult tasks (adaptation). Similar mechanisms are deployed if a task cannot be solved by the usual means because of damage to the brain regions normally involved due to age-related changes or neurodegeneration (compensation)13 . To offset brain functional deterioration, networks and cognitive patterns less susceptible to interference are activated; furthermore, additional networks not involved in young healthy individuals for the same task are recruited. These activity adjustments are exemplified by two well-described phenomena. The PASA (posterioranterior shift in aging) phenomenon describes one possible reaction of the human brain to age-associated cognitive impairment. An increased activation of pre-frontal areas in conjunction with a decreased activation of occipital areas is found for the same cognitive paradigm in elderly individuals compared to healthy young persons. The degree of this activity shift is positively associated with task performance14 . The HAROLD (hemispheric asymmetry reduction in older adults) phenomenon, on the other hand, delineates a reduction of hemispheric asymmetry in elderly individuals15 ; compared to young individuals, elderly persons tend to activate additional contralateral and to deactivate ipsilateral brain regions for the same cognitive task. Again, task performance positively correlates with the degree of the activity change. Taken together, PASA and HAROLD are good examples of the three possible mechanisms of cerebral activity changes associated with efficient information processing during ageing: (i) increased activation of brain regions already involved at the same task difficulty level in young individuals; (ii) activation of additional networks in other brain regions; (iii) more efficient deactivation of interfering networks.
FUNCTIONAL CHANGES IN NEURODEGENERATIVE DISORDERS Neurodegenerative disorders are associated with distinct brain functional patterns. These patterns help to separate different disorders and to identify patients at oligosymptomatic stages.
Mild Cognitive Impairment and Alzheimer’s Disease In Alzheimer’s disease functional brain damage is typically found in the hippocampus, and the pre-frontal, temporoparietal and posterior
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cingulate association cortices8,16 . The hippocampus and the posterior cingulate cortex seem to be affected in very early disease stages; metabolic deterioration of these two regions is already present in patients with mild cognitive impairment (MCI)17,18 . Furthermore, an FDG PET suggestive of Alzheimer’s disease in patients with MCI is a strong predictor for progression to dementia, especially in the presence of other risk factors such as an APOE ε4 allele19 . The degree of posterior cingulate cortex hypometabolism is also positively correlated with clinical disease severity in MCI20 . However, several studies show that there is no linear association between brain damage and clinical symptoms, and that individual characteristics related to cognitive reserve modify the association between neurodegenerative damage and clinical signs21 – 23 . Therefore, clinical symptoms tend to be less severe in individuals with higher estimated cognitive reserve than would be predicted by the amount of their brain damage.
Frontotemporal Lobar Degenerations The clinical syndromes FTD, semantic dementia (SD) and non-fluent progressive aphasia (NFPA) have distinct morphological and functional imaging correlates. Furthermore, associations between specific clinical symptoms and focal functional brain pathology can be established. For example, metabolic reductions in brain regions related to micturition can be found in patients with FTD who suffer from urinary incontinence in contrast to those patients who do not experience this distressing symptom24 . In FTD, bi-hemispheric functional brain pathology, which predominantly affects the pre-frontal cortex, the anterior cingulate cortex, the caudate nucleus and the insula, is already present in early clinical stages25 . As the disease progresses, the functional pathology crosses the boundaries of the pre-frontal cortex and spreads to temporal and parietal regions26 . Davies et al.27 recently reported a group of patients with FTD without any structural brain changes that seem to have a better prognosis. However, brain functional alterations and the clinical relevance of this finding have yet to be explored. It is interesting to note that the degree of functional brain pathology is also influenced by genetic characteristics28 and cognitive reserve29,30 . In SD, initially asymmetric, in most cases left-sided, functional lesions of the temporal cortex, more specifically the temporal pole, are found25 . It was recently shown in a follow-up study that the metabolic deficit only worsened in the anterior cingulate cortex after 15 months; this limited worsening was, however, associated with a considerable clinical decline31 . In NFPA, the asymmetric functional deficit is predominantly located in the left temporal and insular cortex, the caudate nuclei and the thalami32 – 34 . However, right hemispheric functional pathology was reported in left-handed patients35 (Figure 5.1).
Lewy Body-Associated Disorders Parkinson’s disease dementia (PDD) and dementia with Lewy bodies (DLB) probably both belong to a spectrum of Lewy body-associated disorders. This notion is supported by a similar pattern of functional cerebral pathology, which includes brain regions also affected in Alzheimer’s disease, such as the pre-frontal, temporoparietal and posterior cingulate cortex, and additional areas in the visual association cortex36,37 . In a direct comparison, patients with DLB had a significant metabolic reduction in the anterior cingulate cortex compared with patients with PDD36 . Associations between focal metabolic deficits and typical neuropsychiatric symptoms were reported, for
example between right pre-frontal metabolism and delusions38 , and metabolism in visual association areas and visual hallucinations39,40 . Furthermore, the impairment of daily activities was also linked to focal functional brain pathology41,42 .
FUNCTIONAL CHANGES IN PSYCHIATRIC DISORDERS Next we review some studies in major depression and in schizophrenia using fMRI and FDG PET. Since explicit neuroimaging studies exploring the effect of age on major depression and schizophrenia are rare, we focus here on some recent imaging studies in major depression and schizophrenia, providing some new insights in disease mechanisms and demonstrating the potential of neuroimaging techniques for a better understanding of disease-related symptoms by altered brain processes. For both disorders changes in the default mode network (DMN) will be of special interest. The DMN comprises the medial pre-frontal cortex, the posterior cingulate cortex, and the lateral parietal cortex (for review see43 ). Areas of the DMN show elevated metabolism at rest, they are functionally connected by synchronized co-activity at rest and they consistently deactivate across a wide range of attention demanding, goal-directed behaviours; since DMN activation is related to self-referential functions such as remembering the past, planning the future or perspective taking of the mental state of others, deactivations during goal-directed behaviour are suggested as an attenuation of self-referential processes in order to improve goal-oriented attention43 . The first finding pointing at a potential role of the DMN in major depression was reported by Greicius and colleagues44 ; the authors observed increased synchronized co-activity of the medial pre-frontal cortex within the DMN in major depression during rest. Examining the relevance of this result, Sheline et al.45 found that in major depression medial pre-frontal regions of the DMN exhibited failure to deactivate during both looking at negative stimuli and appraising them. Patients with major depression and healthy controls were instructed to look at pictures inducing negative emotions in a passive mode and to appraise them actively (making a negative picture positive by depersonalizing it such that it does not pertain to the viewer or that the picture is not real). For the passive viewing and the active regulating condition patients and controls demonstrated reduced activations compared to the baseline state (i.e. deactivations) in the DMN. However, compared with controls, depressed patients’ deactivations were less distinctive in several areas of the DMN, notably in the medial pre-frontal cortex. This result suggests that patients with major depression might have problems in reducing self-referential processes both during emotion-related activity and also during subsequent emotion regulation. In a similar design to that of Sheline et al. Grimm and colleagues46 found that the degree of deactivation failure correlated with the severity of depressive symptoms and reported hopelessness. These results together point at the prominent role of the DMN in major depression: the DMN seems to be critically involved in some key deficits of major depression such as emotion regulation or increased selffocused cognitions. Several recent studies have revealed substantial changes within the DMN of patients with schizophrenia. Garrity and colleagues47 found reduced synchronized co-activity within superior parts of the posterior cingulate cortex and the precuneus and increased co-activity within the inferior posterior cingulate cortex and the
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(c)
Figure 5.1 Reductions of regional cerebral glucose metabolism in 18 F-fluoro-2-deoxy-glucose positron emission tomography (FDG PET) studies of patients with (a) frontotemporal dementia, (b) semantic dementia and (c) progressive non-fluent aphasia compared with healthy control subjects (sagittal, axial, and coronal slices; areas with reduced metabolism are displayed in colour). A full colour version of this figure appears in the colour plate section medial pre-frontal cortex in patients with schizophrenia during an auditory oddball attention task. In particular, increases in co-activity (i.e. functional hyperconnectivity) were correlated with positive symptoms. Looking at a potential relation between hyperconnectivity within the frontal DMN and already known hyperactivation of areas
within and outside of the DMN in schizophrenia, Whitfield-Gabrieli et al.48 instructed patients with early schizophrenia, first-degree relatives of patients with schizophrenia, and healthy control subjects to perform a working memory task during fMRI. They found gradually reduced deactivations of the medial pre-frontal cortex
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across patients with schizophrenia, relatives of patients and controls with deactivations correlating with the cognitive performance. In the patient group deactivations were related to the severity of positive symptoms. Both patients and relatives hyper-activated in the dorsolateral pre-frontal cortex. With regard to functional connectivity, synchronized co-activity of the medial pre-frontal cortex during rest was highest in patients and lowest in controls. This hyperconnectivity of the medial pre-frontal cortex was related to both the hyperactivity of the dorsolateral pre-frontal cortex and the deactivation of the medial pre-frontal cortex, indicating an association between hyperactivation and hyperconnectivity in schizophrenia. Hyperactivation of the DMN may blur the boundary between internal, self-focus-based thinking and external world-focus-based perceptions. Since many symptoms of schizophrenia involve an increased sense of self-relevance in the world or a smearing of internal reflection and external perception, hyperactivity and hyperconnectivity of the DMN may contribute to these critical symptoms of schizophrenia.
TREATMENT EFFECTS ON BRAIN FUNCTION Including functional neuroimaging in clinical trials and clinical treatment monitoring procedures may identify neurochemical and anatomic differences between treatment responders and nonresponders. These differences may serve as biomarkers for the prediction of treatment response and provide valuable information for treatment development by identifying mechanisms of treatment resistance.
Treatment Effects in Dementia In Alzheimer’s disease, cholinergic treatment with donepezil was associated with a stabilized regional cerebral blood flow in treatment responders, whereas blood flow declined in non-responders in a study by Nobili et al.49 . Similar treatment effects of donepezil were also shown in patients with cognitive impairment after traumatic brain injury50 . The binding of donepezil to acetylcholinesterase can also be directly measured in vivo with PET, allowing quantitative analyses of acetylcholinesterase and direct investigation of the pharmacokinetics of donepezil in the human brain51 . Okamura et al.52 reported that up to 60% of acetylcholinesterase donepezil-binding sites were occupied after the oral application of 5 mg donepezil. Cholinergic treatment with galantamine also caused sustained inhibition of acetylcholinesterase activity in patients with Alzheimer’s disease; this effect was associated with attentional rather than memory improvement53 . Brain functional changes were also demonstrated for drugs targeting transmitter systems other than the cholinergic system. Fellgiebel et al.54 , for example, reported clinical and brain metabolic improvements in a patient with FTD under treatment with aripiprazole, a newer antipsychotic with partial agonistic properties at serotonin 5-HT1A and dopamine D2 receptors, and partial antagonism at serotonin 5-HT2 receptors. This study also suggests that common functional imaging techniques can be used to provide neurobiological evidence for the clinical effects of different psychotropic drugs.
psychotherapy56 and electroconvulsive therapy57 , focus on mid-life individuals. The available data in geriatric depression are limited. Nobler et al.58 reported that after treatment with nortriptyline or sertraline, the study group as a whole did not show any blood flow changes; furthermore, there were no global blood flow differences between treatment responders and non-responders. However, the blood flow pattern differed significantly between treatment responders and non-responders: responders showed regional blood flow reductions in the pre-frontal and anterior temporal cortices. Brain metabolic reductions in the anterior cingulate cortex and the amygdalae were observed under chronic citalopram treatment by Liotta et al.59 ; the reductions were greater in responders than in non-responders. Wu et al.60 showed that improvement under treatment with sertraline and after sleep deprivation was associated with a metabolic decrease in the orbitofrontal cortex, whereas clinical worsening was related to a metabolic increase in the dorsolateral pre-frontal cortex. Early metabolic decreases of the right cingulate gyrus after total sleep deprivation in combination with sertraline treatment were furthermore associated with clinical improvement61 . However, these synergistic effects of antidepressant drug and sleep deprivation could not be replicated in a randomized, placebo-controlled study by the same group62 . Taken together these results suggest that the state of severe depression is associated with increased functional activity, the reduction of which through different antidepressant therapies is linked to clinical improvement.
CLINICAL APPLICATION AND FUTURE PERSPECTIVES Functional Neuroimaging in Clinical Practice Structural imaging of the brain is an integral diagnostic procedure in psychiatry. It can provide indispensable information on possible organic aetiologies of psychiatric disorders, sometimes with immediate therapeutic consequences; furthermore, structural imaging can also support the clinical diagnosis in geriatric psychiatry, such as in the case of marked mediotemporal atrophy in Alzheimer’s disease63 . However, functional imaging techniques are experiencing increased popularity in the search for more sensitive and specific biomarkers for distinct psychiatric disorders. For a limited number of indications, functional imaging studies are already recommended by diagnostic guidelines. These indications include the assessment of regional cerebral blood flow or metabolism by means of PET or SPECT imaging for the differentiation of Alzheimer’s disease and other neurodegenerative dementias such as FTD. Functional imaging should, however, never replace structural imaging; functional imaging should rather be used to provide complementary information in uncertain clinical cases. The added clinical value of functional imaging in several psychiatric and neurological disorders, including major depression and schizophrenia, is still to be determined. The identification of responders and non-responders in early treatment phases or even before starting a treatment would be especially desirable. Furthermore, novel imaging procedures such as resting state fMRI (rs-fMRI) could not only help to clarify the brain functional basis of neurodegenerative and psychiatric disorders but also serve as non-invasive biomarkers for the diagnosis and differential diagnosis in geriatric psychiatry64 .
Future Perspectives Treatment Effects in Geriatric Depression Most studies on antidepressant interventions in unipolar depression, including antidepressant drugs3 , total sleep deprivation55 ,
Representing a new tool of functional neuroimaging research with some potential for reaching clinical relevance in psychiatric disorders, rs-fMRI focuses on changes of functional interactions between
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Figure 5.2 Brain networks characterized by synchronized co-activity during rest in normal controls (NC) and patients with mild cognitive impairment (MCI) detected by 4 min of resting state functional magnetic resonance imaging (fMRI). Brain networks correspond with networks found during characteristic cognitive task conditions such as seeing or attending. Selectively in both networks of part f/F patients had reduced co-activity compared with controls: the default mode network and an attention network
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Figure 5.3 The functional connectivity at rest within the default mode network (DMN) correlates with psychopathology in patients with schizophrenia. Psychopathology reflects positive symptoms (composite Scale for the Assessment of Positive Symptoms (SAPS) score of positive symptoms); connectivity reflects whole brain functional connectivity with seed in the medial pre-frontal cortex. Adapted with permission from data published in Whitfield-Gabrieli et al.48 brain areas. Since it is performed at rest, rs-fMRI only needs minimal compliance of patients during imaging, making it appropriate for clinical purposes. Because it focuses on interactions between brain areas, rs-fMRI detects functional changes characteristic of several psychiatric disorders (Figures 5.2 and 5.3)65 . In addition to this new brain mapping tool, several other new approaches aim at the integration of distinct structural and functional imaging parameters. Of particular note, machine learningrelated methods such as support vector machines and various clustering procedures have been used. The basic idea of these approaches is to identify distinct patterns that are specific for a set of patients66 . However, further research is warranted to explore the real potential of these newer methods.
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2. Foster NL, Heidebrink JL, Clark CM et al. FDG-PET improves accuracy in distinguishing frontotemporal dementia and Alzheimer’s disease. Brain 2007; 130: 2616–35. 3. Brockmann H, Zobel A, Joe A et al. The value of HMPAO SPECT in predicting treatment response to citalopram in patients with major depression. Psychiatry Res 2009; 173: 107–12. 4. Mosconi L, Mistur R, Switalski R et al. Declining brain glucose metabolism in normal individuals with a maternal history of Alzheimer disease. Neurology 2009; 72: 513–20. 5. Raichle ME, Mintun M. Brain work and brain imaging. Annu Rev Neurosci 2006; 29: 449–76. 6. Cohen J, Tong F. Neuroscience. The face of controversy. Science 2001; 293: 2405–407. 7. Kalpouzos G, Chetelat G, Baron JC et al. Voxel-based mapping of brain gray matter volume and glucose metabolism profiles in normal ageing. Neurobiol Aging 2009; 30: 112–24. 8. Mosconi L, Tsui WH, Herholz K et al. Multicenter standardized 18F-FDG PET diagnosis of mild cognitive impairment, Alzheimer’s disease, and other dementias. J Nucl Med 2008; 49: 390–98.
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9. Caselli RJ, Chen K, Lee W et al. Correlating cerebral hypometabolism with future memory decline in subsequent converters to amnestic pre-mild cognitive impairment. Arch Neurol 2008; 65: 1231–36. 10. Mosconi L, Mistur R, Switalski R et al. FDG-PET changes in brain glucose metabolism from normal cognition to pathologically verified Alzheimer’s disease. Eur J Nucl Med Mol Imaging 2009; 36: 811–22. 11. Rimajova M, Lenzo NP, Wu JS et al. Fluoro-2-deoxy-D-glucose (FDG)-PET in APOEepsilon4 carriers in the Australian population. J Alzheimers Dis 2008; 13: 137–46. 12. Mosconi L, Sorbi S, de Leon MJ et al. Hypometabolism exceeds atrophy in presymptomatic early-onset familial Alzheimer’s disease. J Nucl Med 2006; 47: 1778–86. 13. Stern Y, Habeck C, Moeller J et al. Brain networks associated with cognitive reserve in healthy young and old adults. Cereb Cortex 2005; 15: 394–402. 14. Davis SW, Dennis NA, Daselaar SM et al. Que PASA? The posterior-anterior shift in ageing. Cereb Cortex 2008; 18: 1201–209. 15. Cabeza R Hemispheric asymmetry reduction in older adults: the HAROLD model. Psychol Aging 2002; 17: 85–100. 16. Herholz K, Salmon E, Perani D et al. Discrimination between Alzheimer dementia and controls by automated analysis of multicenter FDG PET. Neuroimage 2002; 17: 302–16. 17. Mosconi L, Tsui WH, de Santi S et al. Reduced hippocampal metabolism in MCI and AD: automated FDG-PET image analysis. Neurology 2005; 64: 1860–67. 18. Minoshima S, Giordani B, Berent S et al. Metabolic reduction in the posterior cingulate cortex in very early Alzheimer’s disease. Ann Neurol 1997; 42: 85–94. 19. Drzezga A, Grimmer T, Riemenschneider M et al. Prediction of individual clinical outcome in MCI by means of genetic assessment and18 F-FDG PET. J Nucl Med 2005; 46: 1625–32. 20. Perneczky R, Hartmann J, Grimmer T et al. Cerebral metabolic correlates of the clinical dementia rating scale in mild cognitive impairment. J Geriatr Psychiatry Neurol 2007; 20: 84–88. 21. Perneczky R, Drzezga A, Diehl-Schmid J et al. Schooling mediates brain reserve in Alzheimer’s disease: findings of fluorodeoxy-glucose-positron emission tomography. J Neurol Neurosurg Psychiatry 2006; 77: 1060–63. 22. Scarmeas N, Zarahn E, Anderson KE et al. Association of life activities with cerebral blood flow in Alzheimer disease: implications for the cognitive reserve hypothesis. Arch Neurol 2003; 60: 359–65. 23. Perneczky R, Wagenpfeil S, Lunetta K et al. Education attenuates the effect of medial temporal lobe atrophy on cognitive function in Alzheimer’s disease: the MIRAGE study. J Alzheimers Dis 2009; 17: 855–962. 24. Perneczky R. Therapie der frontotemporalen Demenz. Z Psychiatr Psychol Psychother 2007; 56: 47–49. 25. Diehl J, Grimmer T, Drzezga A et al. Cerebral metabolic patterns at early stages of frontotemporal dementia and semantic dementia. A PET study. Neurobiol Aging 2004; 25: 1051–56. 26. Diehl-Schmid J, Grimmer T, Drzezga A et al. Decline of cerebral glucose metabolism in frontotemporal dementia: a longitudinal 18F-FDG-PET-study. Neurobiol Aging 2007; 28: 42–50. 27. Davies RR, Kipps CM, Mitchell J et al. Progression in frontotemporal dementia: identifying a benign behavioral variant by magnetic resonance imaging. Arch Neurol 2006; 63: 1627–31.
28. Laws SM, Perneczky R, Drzezga A et al. () Association of the tau haplotype h2 with age at onset and functional alterations of glucose utilization in frontotemporal dementia. Am J Psychiatry 2007; 164: 1577–84. 29. Perneczky R, Diehl-Schmid J, Drzezga A et al. Brain reserve capacity in frontotemporal dementia: a voxel-based18 F-FDG PET study. Eur J Nucl Med Mol Imaging 2007; 34: 1082–87. 30. Borroni B, Premi E, Agosti C et al. Revisiting brain reserve hypothesis in frontotemporal dementia: evidence from a brain perfusion study. Dement Geriatr Cogn Disord 2009; 28: 130–35. 31. Diehl-Schmid J, Grimmer T, Drzezga A et al. Longitudinal changes of cerebral glucose metabolism in semantic dementia. Dement Geriatr Cogn Disord 2006; 22: 346–51. 32. Nestor PJ, Balan K, Cheow HK et al. Nuclear imaging can predict pathologic diagnosis in progressive nonfluent aphasia. Neurology 2007; 68: 238–39. 33. Nestor PJ, Graham NL, Fryer TD et al. Progressive non-fluent aphasia is associated with hypometabolism centred on the left anterior insula. Brain 2003; 126: 2406–18. 34. Perneczky R, Diehl-Schmid J, Pohl C et al. Non-fluent progressive aphasia: Cerebral metabolic patterns and brain reserve. Brain Res 2007; 1133: 178–85. 35. Drzezga A, Grimmer T, Siebner H et al. Prominent hypometabolism of the right temporoparietal and frontal cortex in two left-handed patients with primary progressive aphasia. J Neurol 2002; 249: 1263–67. 36. Yong SW, Yoon JK, An YS et al. A comparison of cerebral glucose metabolism in Parkinson’s disease, Parkinson’s disease dementia and dementia with Lewy bodies. Eur J Neurol 2007; 14: 1357–62. 37. Minoshima S, Foster NL, Sima AA et al. Alzheimer’s disease versus dementia with Lewy bodies: cerebral metabolic distinction with autopsy confirmation. Ann Neurol 2001; 50: 358–65. 38. Perneczky R, Drzezga A, Boecker H et al. Right prefrontal hypometabolism predicts delusions in dementia with Lewy bodies. Neurobiol Aging 2008; 30: 1420–29. 39. Boecker H, Ceballos-Baumann AO, Volk D et al. Metabolic alterations in patients with Parkinson disease and visual hallucinations. Arch Neurol 2007; 64: 984–88. 40. Perneczky R, Drzezga A, Boecker H et al. Cerebral metabolic dysfunction in patients with dementia with Lewy bodies and visual hallucinations. Dement Geriatr Cogn Disord 2008; 25: 531–38. 41. Perneczky R, Drzezga A, Boecker H et al. Activities of daily living, cerebral glucose metabolism, and cognitive reserve in Lewy body and Parkinson’s disease. Dement Geriatr Cogn Disord 2008; 26: 475–81. 42. Perneczky R, Haussermann P, Drzezga A et al. Fluoro-deoxyglucose positron emission tomography correlates of impaired activities of daily living in dementia with Lewy bodies: implications for cognitive reserve. Am J Geriatr Psychiatry 2009; 17: 188–95. 43. Buckner R, Andrews-Hanna J, Schacter D. The brain’s default network: anatomy, function, and relevance to disease. Ann N Y Acad Sci 2008; 1124: 1–38. 44. Greicius M, Flores B, Menon V et al. Resting-state functional connectivity in major depression: abnormally increased contributions from subgenual cingulate cortex and thalamus. Biol Psychiatry 2007; 62: 429–37.
NORMAL AND ABNORMAL AGEING 45. Sheline Y, Barch D, Price J et al. The default mode network and self-referential processes in depression. Proc Natl Acad Sci USA 2009; 106: 1942–47. 46. Grimm S, Boesinger P, Beck J et al. Altered negative BOLD responses in the default-mode network during emotion processing in depressed subjects. Neuropsychopharmacology 2009; 34: 932–43. 47. Garrity A, Pearlson G, McKiernan K et al. Aberrant ‘default mode’ functional connectivity in schizophrenia. Am J Psychiatry 2007; 164: 450–57. 48. Whitfield-Gabrieli S, Thermenos H, Milanovic S et al. Hyperactivity and hyperconnectivity of the default mode network in schozophrenia and in first-degree relatives of persons with schizophrenia. Proc Natl Acad Sci USA 2009; 106: 1279–84. 49. Nobili F, Koulibaly M, Vitali P et al. Brain perfusion follow-up in Alzheimer’s patients during treatment with acetylcholinesterase inhibitors. J Nucl Med 2002; 43: 983–90. 50. Kim YW, Kim DY, Shin JC et al. The changes of cortical metabolism associated with the clinical response to donepezil therapy in traumatic brain injury. Clin Neuropharmacol 2009; 32: 63–68. 51. Hiraoka K, Okamura N, Funaki Y et al. Quantitative analysis of donepezil binding to acetylcholinesterase using positron emission tomography and [5-(11)C-methoxy]donepezil. Neuroimage 2009; 46: 616–23. 52. Okamura N, Funaki Y, Tashiro M et al. In vivo visualization of donepezil binding in the brain of patients with Alzheimer’s disease. Br J Clin Pharmacol 2008; 65: 472–79. 53. Kadir A, Darreh-Shori T, Almkvist O et al. PET imaging of the in vivo brain acetylcholinesterase activity and nicotine binding in galantamine-treated patients with AD. Neurobiol Aging 2008; 29: 1204–17. 54. Fellgiebel A, Muller MJ, Hiemke C et al. Clinical improvement in a case of frontotemporal dementia under aripiprazole treatment corresponds to partial recovery of disturbed frontal glucose metabolism. World J Biol Psychiatry 2007; 8: 123–26. 55. Gillin JC, Buchsbaum M, Wu J et al. Sleep deprivation as a model experimental antidepressant treatment: findings from functional brain imaging. Depress Anxiety 2001; 14: 37–49. 56. Brody AL, Saxena S, Stoessel P et al. Regional brain metabolic changes in patients with major depression treated with either paroxetine or interpersonal therapy: preliminary findings. Arch Gen Psychiatry 2001; 58: 631–40.
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57. Henry ME, Schmidt ME, Matochik JA et al. The effects of ECT on brain glucose: a pilot FDG PET study. J ECT 2001; 17: 33–40. 58. Nobler MS, Roose SP, Prohovnik I et al. Regional cerebral blood flow in mood disorders, V.: Effects of antidepressant medication in late-life depression. Am J Geriatr Psychiatry 2000; 8: 289–96. 59. Liotti M, Mayberg HS, Brannan SK et al. Differential limbic–cortical correlates of sadness and anxiety in healthy subjects: implications for affective disorders. Biol Psychiatry 2000; 48: 30–42. 60. Wu JC, Gillin JC, Buchsbaum MS et al. Sleep deprivation PET correlations of Hamilton symptom improvement ratings with changes in relative glucose metabolism in patients with depression. J Affect Disord 2008; 107: 181–86. 61. Smith GS, Reynolds CF, 3rd, Houck PR et al. Glucose metabolic response to total sleep deprivation, recovery sleep, and acute antidepressant treatment as functional neuroanatomic correlates of treatment outcome in geriatric depression. Am J Geriatr Psychiatry 2002; 10: 561–67. 62. Smith GS, Reynolds CF, 3rd, Houck PR et al. Cerebral glucose metabolic response to combined total sleep deprivation and antidepressant treatment in geriatric depression: a randomized, placebo-controlled study. Psychiatry Res 2009; 171: 1–9. 63. Jack CR, Jr., Dickson DW, Parisi JE et al. Antemortem MRI findings correlate with hippocampal neuropathology in typical ageing and dementia. Neurology 2002; 58: 750–57. 64. Sorg C, Riedl V, Perneczky R, Kurz A, Wohlschl¨ager AM. Impact of Alzheimer’s disease on the functional connectivity of spontaneous brain activity. Curr Alzheimer Res 2009; 6: 541–53. 65. Sorg C, Riedl V, Muhlau M et al. Selective changes of restingstate networks in individuals at risk for Alzheimer’s disease. Proc Natl Acad Sci USA 2007; 104: 18760–65. 66. Schmidt J, Hapfelmeier A, Mueller M et al. Interpreting PET scans by structured patient data: a data mining case study in dementia research. KAIS 2009; 23 Jul 2009 (epub).
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Neurophysiology of the Ageing Brain Paolo Maria Rossini and Laura Parisi Clinica Neurologica University Campus Bio-Medico, Rome, Italy
INTRODUCTION The few individuals who reach very old age are called ‘longevity outliers’. This particular group represents the fastest growing age group worldwide. For instance, the number of centenarians increases steadily in the US population and their numbers are expected to grow to more than 400 000 in the next 30 years1 . Awareness of age-related diseases such as dementia has prompted considerable interest in the study of the ageing human brain to trace a clear boundary between physiological and pathological ageing, to carry out primary prevention on populations at high risk of developing dementia, to achieve secondary prevention and to apply eventual disease-modifying therapy to at-risk subjects. Results from these types of studies could be used to plan political and public health interventions. Recent investigations have prompted advancement in biochemical, structural, functional and neurophysiological fields. Ageing is a physiological dynamic process due to a specific property of the central nervous system (CNS) known as neuronal plasticity. The concept of ‘plasticity’ applied to neurobiology typically denotes the potential for change in addition to the mechanisms of self-repair and/or of reorganization of neural connections. Neural plasticity underlies learning as well as endogenous brain function repair2 , including synaptic efficacy and synaptic redundancy; on this basis the functional status and distribution of a network depends on the balance between neural excitation and inhibition, with some areas appearing silent or ‘masked’ by a mechanism of active tonic inhibition, the latter being prone to alteration or removal, causing a rapid change of the functional network, a process termed ‘unmasking’3 . Additional mechanisms include long-term potentiation (LTP) and long-term depression (LTD), which contribute to the functional strengthening or weakening of existing synapses by which information is stored in the CNS. LTP has been regarded as the prototypic mechanism of modified synaptic efficacy, and it can differently occur via modification of the input to a postsynaptic cell, the concomitant synchronous input to the synapse from another cell, or postsynaptic depolarization. LTD stems from Na+ or Ca2+ channels at least for short-term changes, while LTP-like mechanisms include glutamate-dependent NMDA receptor activation for long-term changes, a process that can be antagonized by GABA inhibition4 . Another plasticity-related process is neuronal sprouting and formation of new synapses influenced by local neurotransmitter,
neurotrophic factors and synaptic protein synthesis5 . In particular, dendrites and related spines with synaptic connections undergo continuous remodelling most likely also modulated by interaction with neighbouring astrocytes4 . Postmortem examinations show that brain ageing is characterized by the formation of neurofibrillary tangles and senile plaques in both cognitively intact individuals and patients with dementia, namely Alzheimer’s disease1 . The ubiquitous presence of these lesions and the steady increase of the prevalence of dementia up to 85 years have strongly supported a continuum between normal and pathological brain ageing. Ageing is a physiological process that occurs asynchronously in different areas of the brain, its rate being also dependent on the style of life. The differential age-related changes produced in several regions of the brain in the anatomy of neurons, volume tissue, density and dynamics of several neurotransmitters give support to this suggestion6 . From a macroscopic point of view, brain ageing becomes evident by atrophy. In 1955 Brody estimated that the neuronal loss was about 40%. In 1986 Braak and Braak specified that during the ageing, especially pyramidal cells of frontal lobes die. Some studies suggest that the primum movens is a functional and then a structural modification of synapses7 . It is followed by a modification of the dendritic tree and then by the neuronal death, today known as aposklesis. Particularly, the hippocampus seems to be one of the most vulnerable structures in brain ageing. Functional modifications precede the structural ones, so it is hoped that by integrating structural techniques with the functional ones it will be possible to better investigate brain ageing. Moreover, modern neurophysiological techniques (transcranial magnetic stimulation, TMS; electroencephalography, EEG; magnetoencephalography, MEG; event-related potentials, EPRs) could be helpful for this purpose, being of low cost and non-invasive8 . Modern techniques of functional neurophysiological imaging allow investigation with high accuracy of the cortico-cortical ‘connectivity’ that is the base for synchronization and functional binding. These phenomena allow neuronal populations, even at a distance, to contribute to a specific task or to process a specific input working together only for a few milliseconds. Analysis of EEG and MEG signals and TMS techniques gives us worthwhile information about that.
Principles and Practice of Geriatric Psychiatry, 3rd edn. Edited by Mohammed T. Abou-Saleh, Cornelius Katona and Anand Kumar 2011 John Wiley & Sons, Ltd
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TRANSCRANIAL MAGNETIC STIMULATION TMS is a brief and intense magnetic field, created by a strong electric current circulating within a coil resting on the scalp; it penetrates human tissue painlessly and, if the current amplitude, duration and direction are appropriate, it induces in the brain (or in spinal roots, or in nerves) electric currents that can depolarize neurons or their axons. TMS can demonstrate causal relationships between the stimulated area and behaviour. It can be used to interfere with the neuronal activity underlying sensory processing, motor planning or execution, attention and visual processing or awareness, different forms of declarative and non-declarative memory, reasoning, mathematics, language and consciousness. This temporary disruptive effect of TMS on cortical function is often referred to as a ‘virtual lesion’ and is likely to occur because the stimulus transiently synchronizes the activity of a large proportion of neurons under the coil, thus inducing a long-lasting, generalized inhibitory postsynaptic potential that reduces cortical activity for the next 50 to 200 milliseconds, depending on stimulus intensity and duration. Moreover, repetitive TMS (rTMS) can produce changes – outlasting the period of stimulation – in cortical excitability9 . rTMS studies are increasing knowledge about correlation between anatomic structures and their functions. For example, they showed that dorsolateral prefrontal cortex (DLPCF) is implicated in working memory and in verbal episodic memory tasks. Lesions of frontal lobes cause a reduction of learning and memory abilities but they do not cause the same memory loss as bilateral hippocampal lesions do. So, it has been demonstrated that prefrontal cortex (PFC) is involved in episodic memory tasks and that during encoding or retrieval, there are different areas of PFC that are activated with different patterns. It has been demonstrated that left PFC is involved in encoding processes; instead right PFC is involved in retrieval processes. This theory is known as hemispherical encoding retrieval asymmetry (HERA)9 – 11 . Nowadays, it is known that the HERA model is not so absolute but that there could be variations due to the nature of the presented stimuli, the strategies of memorization used and the grade of difficulty of the task. Recently, positron emission tomography (PET) and functional magnetic resonance imaging (fMRI) studies have demonstrated that PFC activity tends to be less asymmetric in older than in younger adults (hemispheric asymmetry reduction in old adults, HAROLD). This change may help counteract age-related neurocognitive decline (compensation hypothesis) or it may reflect an age-related difficulty in recruiting specialized neural mechanisms (dedifferentiation hypothesis)12,13 . Functional neuroimaging techniques could not be used to study whether the loss of asymmetry during ageing reflects compensatory mechanisms or dedifferentiation processes; in fact, they show only the activation of a specific area during a task, but this activation could be related to the performance of the task without being the cause. Instead, this issue was addressed by using rTMS to assess causal relationships between performance and stimulated brain regions. Rossi et al. studied the effects of rTMS applied to the left or right DLPFC simultaneously with the presentation of memoranda on visuo-spatial recognition memory task, in a population of healthy subjects divided into two classes by age (<45 and >50 years). In the younger subjects, rTMS of the right DLPFC interfered with retrieval more than left DLPFC stimulation. The asymmetry of the effect progressively vanished with ageing, as indicated by bilateral interference effects on recognition performance. Conversely, the predominance of left DLPFC effect during encoding was not abolished in the older subjects, thereby indicating its causal role
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for encoding along the life span. Findings with rTMS suggest that the bilateral engagement of the DLPFC has a compensatory role on episodic memory performance across the age span13 .
CORTICAL EXCITABILITY Physiological ageing is associated with more complex activations of the motor system to compensate for the reduced skill in motor performance14,15 . Therefore, TMS variables can provide useful clues to investigate causally subclinical changes of cortical excitability at the motor cortex level. Unfortunately, studies do not show converging findings, probably as a result of technical and experimental differences among them13,16 – 18 . Apart from assessing cortical excitability, TMS can be used to measure intracortical facilitatory and inhibitory mechanisms resulting from the balance among neurotransmitters, and dynamic synaptic adaptations to progressive neuronal loss. Motor threshold is generally reduced in Alzheimer’s disease compared to healthy age-matched controls and is similarly reduced in subcortical ischaemic vascular dementia16,19,20 , even if several reports have not found reduction of motor thresholds21,22 , with one study noting increased rather than decreased motor thresholds in Alzheimer’s disease23 . Global cortical hyperexcitability while the brain is ‘at rest’ in Alzheimer’s disease is a consistent result22 , which seems to occur independently of GABAergic and cholinergic cortico-cortical mechanism dysfunction as reduced motor thresholds and intracortical inhibition (ICI) and short-latency afferent inhibition (SAI) are uncorrelated. Since TMS does not provide specific pathophysiological information but is sensitive to the ‘global weight’ of several neurotransmitters as well as subcortical and cortical motor inputs, interpretation of cortical hyperexcitability in Alzheimer’s disease is not yet possible. The majority of these TMS results indicate that the cortex of Alzheimer’s disease patients is hyperexcitable, and that such hyperexcitability may offer clues for the differential diagnosis from other dementias in which the cholinergic deficit is not predominant. An intriguing issue that can be addressed by TMS is the study of cortical reorganization of the motor output in Alzheimer’s disease. Indeed, motor cortex physiological organization is early involved in Alzheimer’s disease, despite the lack of clinically evident motor deficits, which only appear later24 . This observation is not surprising considering that the motor cortex, through muscarinic receptors and cholinergic terminals, receives a major input from the nucleus basalis of Meynert25 . Mapping of motor output in mild Alzheimer’s disease patients asymptomatic for motor deficits has demonstrated frontal and medial shift of the cortical motor maps for hand muscles. In healthy controls the centre of gravity of motor cortical output is coincident with the site of maximal excitability (hot spot26 ), whereas in Alzheimer’s disease patients it shifts towards frontal and medial regions in the absence of changes in the hot spot22 . An altered synaptic plasticity in Alzheimer’s disease also has been demonstrated by applying brief trains of high-frequency rTMS to motor cortex and recording motor-evoked potentials (MEPs) from the contralateral hand muscles. This procedure can induce a progressive increase in MEP size in normal age-matched controls, but it produces opposite changes in Alzheimer’s disease. This finding was interpreted as an altered short-term synaptic enhancement in excitatory circuits of the motor cortex. Additional assessment of these findings will be required by evaluating Alzheimer’s disease patients after different pharmacological treatments (e.g. cholinergic versus drugs acting on NMDA glutamate receptors).
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In summary, TMS assays of cortical disinhibition in Alzheimer’s disease as a dysfunction of a single neurotransmitter in a single neural circuit or as the net effect of a complex involvement of more than one neurotransmitter system in several brain areas likely reflects a single facet of a pathological mosaic. A lasting preclinical condition under the attack of pro-degenerative agents could produce the Alzheimer’s disease brain as alternative strategies of functioning belonging to the brain reserve even for the execution of simple motor tasks15,22 . The emerging evidence indicates that the ‘stressed synapses’ may acquire a different function both in terms of effects and of utilized neurotransmitter and may be strongly dependent on the sampling time of the tested patients27 . rTMS could be useful to improve cognitive performance in healthy subjects or in patients with mild cognitive impairment (MCI). These effects include selective shortening of picture naming28 and action naming without changing verbal reaction times for naming objects29 , improving subjects’ speed at finding the solution to a reasoning puzzle30 , and improving performance on a choice reaction task31 . It can be hypothesized that rTMS – by shifting the level of cortical excitability – might allow either more or less access (by interfering, for example, with the functioning of local inhibitory circuits) to brain networks relevant to the experimental task. These effects might vary depending on the timing of the TMS stimulation and on the hierarchical role of the brain area stimulated within the whole functional network underpinning the function under investigation. These findings reflect the potential of rTMS to recruit compensatory networks that underlie the memory-encoding process and suggest that rTMS is capable of transient and positive rehabilitative influences on brain function9,32 .
EEG/MEG RHYTHMS Advanced EEG analysis techniques together with analysis of MEG signals contribute to the investigation of brain ageing. Among EEG analysis techniques, the most worthy are the surface Laplacian transformation or coherence analysis of EEG, which can illustrate changes in specific oscillatory frequencies over time and can provide quantitative measurements of individual rhythm33 . Moreover, the low resolution electromagnetic topography algorithm (LORETA) technique computes three-dimensional linear solutions from multi-channel input to localize generators in the brain from the EEG field distribution on the scalp by employing a three-shell spherical head model of the scalp, skull and brain compartments34 . LORETA solutions consist of voxel z-current density values that are used to predict EEG spectral power density at scalp electrodes. A normalization method yields current density at each voxel for the power density averaged across all frequencies (0.5–45 Hz) and voxels of the brain volume. Instead, MEG is a non-invasive technique that permits spatial identification of neuronal activation from spontaneous cerebral or external stimulus presentation. MEG signal characteristics are not influenced by extracerebral tissue layers (i.e. meninges, skull, scalp, muscles). MEG signals originate from current flow of tangential dipoles in cortical gyri and sulci35,36 . The signals reflect the spatial and temporal production of a dipolar source modelled as an equivalent current dipole (ECD). This method provides three-dimensional localization of dipolar field distributions over the scalp with time resolution of milliseconds. Hence, MEG signals can directly estimate the number of active neural pools and provide accurate measures of the intracellular currents in a limited shallow brain region below the recording sensor without influence from volume conduction.
Resting EEG changes across physiological ageing, with gradual changes in spectral power profile indicating a pronounced amplitude decrease of alpha (8–13 Hz) and a global ‘slowing’ of the background EEG, with increases in power and topographic location in the slower delta (2–4 Hz) and theta (4–8 Hz) frequency ranges37 – 39 . Ageing effects on parieto-occipital alpha rhythms reflect the activity of dominant oscillatory neural network modulated by thalamocortical and cortico-cortical interactions facilitating/inhibiting the transmission of sensorimotor information and the retrieval of semantic information from cortical storage40,41 . Low-frequency alpha is primarily related to the subject’s global attentive readiness, whereas high-frequency alpha reflects the oscillation of neural systems for the elaboration of sensorimotor or semantic information39 . Over the course of age, alpha power decreases combined with changes in cholinergic basal forebrain system and in the excitatory activity in the cholinergic brainstem pathway42 . Despite the relative consensus on alpha decrease, there is no general agreement on the modulation of delta and theta activity in brain ageing43 . Resting EEG changes in pathological brain ageing. When compared to healthy normal elderly (Nold) subjects, Alzheimer’s disease patients exhibit high power for delta and theta and low power for posterior alpha (8–12 Hz) and/or beta (13–30 Hz) frequencies44 – 47 . EEG abnormalities were associated with altered regional blood flow/metabolism and with impaired global cognitive function as evaluated by Mini-Mental State Examination (MMSE)48,49 . MEG also has provided contributions to the understanding of the cortical rhythms in pathological ageing. Parieto-temporal delta and theta sources enhanced in power in Alzheimer’s disease compared to Nold subjects in association with hippocampal atrophy50 . Furthermore, Alzheimer’s disease subjects demonstrated a decrease of alpha sources in parieto-occipital region possibly compensated by an increase of temporal alpha sources51 . Finally, cortical theta and alpha rhythms as revealed by MEG have discriminated the severity level of Alzheimer’s disease and distinguished it from Lewy body dementia. EEG power per se does not capture one of the main features of Alzheimer’s disease, namely the impairment of functional neural connectivity. It has been reported that Alzheimer’s disease patients present an abnormal linear coupling of EEG rhythms among cortical regions, as revealed by spectral EEG coherence52 – 56 , suggesting a linear temporal synchronicity of coupled EEG rhythms from simultaneously engaged neural sources. Such findings imply that functional coupling of cortical rhythms is modulated by cholinergic systems, and that a decrease of cortical EEG coherence may be a fine-grained marker of Alzheimer’s disease, since it is characterized by defective basal forebrain cholinergic inputs to cortex and hippocampus57 . Most EEG studies of Alzheimer’s disease have reported a prominent decrease of alpha band coherence52,54 – 56,58 – 60 . This result also has been found to be associated with ApoE genetic risk, which is hypothesized to be mediated by cholinergic deficit52 . However, delta and theta band coherence changes in Alzheimer’s disease are not homogeneous, as some studies demonstrate a decrease of slow-band EEG coherence, whereas others find an increase56,61 . MCI subjects present an intermediate magnitude of low-frequency alpha (8–10.5 Hz) activity from parietal, occipital and limbic areas, compared to mild Alzheimer’s disease and normal elderly62 . Increase of slow EEG power coupled with a decrease in alpha activity is linked to cognitive performance decline in MCI patients compared to Nold. More importantly, the magnitude of these sources is correlated negatively with MMSE scores across subjects of the three groups, suggesting that EEG evidence of alpha power decrease in MCI compared to normal subjects is related to behavioural cognition60,63 – 65 .
NORMAL AND ABNORMAL AGEING The relative decrement of posterior low-frequency alpha sources in MCI may be related to an initial selective impairment of the cholinergic basal forebrain, which could induce a sustained increase of the excitatory activity in the cholinergic brainstem pathway42 . As a consequence, the increased excitability of thalamo-cortical connections would desynchronize the resting alpha rhythms and enhance the cortical excitability as seen in Alzheimer’s disease. Hence, changes of low-frequency alpha power in MCI and mild Alzheimer’s disease suggest a progressive impairment of the thalamo-cortical and cortico-cortical systems that govern visual attention. This hypothesis is consistent with clinical findings of increasing deficits of visuospatial abilities in MCI and mild Alzheimer’s disease. Similarly, limbic sources imply a progressive impairment of thalamo-cortical and cortico-cortical systems regulating attention tone for memory functions. Quantitative EEG is able to predict with a good approximation MCI progression to Alzheimer’s disease in a short run; this was demonstrated by Rossini et al.66 , who investigated whether combined analysis of EEG power and coherence provides early and reliable discrimination of MCI subjects who will convert to Alzheimer’s disease after a relatively brief follow-up. EEG and MEG rhythms can change over time in relation to a specific event. Event-related desynchronization (ERD) and event-related synchronization (ERS) of EEG or MEG rhythms describe neuroelectric events preceding and following a task execution39 . ERD/ERS is defined as reduction/increase in EEG power during event (sensory, motor, cognitive) when compared to baseline at a certain frequency band. Alpha band hyper-reactivity in Alzheimer’s disease as indexed by increased alpha ERD suggests an abnormal increase of the cortical excitation or disinhibition even during simple cognitive demands. Such findings agree with previous functional neuroimaging studies on memory, which demonstrated a stronger allocation of cortical resources in Alzheimer’s disease when compared to Nold subjects66,67 . In addition, they are consonant with other findings of abnormal central rhythms when processing sensory stimuli or performing voluntary movements and with hyper-reactivity of Alzheimer’s disease primary motor cortex as revealed by TMS15,68 . Artificial neural networks (ANNs) are a useful tool in early diagnosing of dementia; they elaborate in an innovative way EEG signals. Starting from a standard EEG recorded with the international 10–20 system, it is a low cost and non-invasive procedure, it is widespread and it does not require highly qualified staff at the moment of recording. It has been shown that a correct automatic classification of MCI and Alzheimer’s disease subjects can be obtained extracting spatial information content of the resting EEG voltage by ANNs with an accuracy greater than 92%69 . Moreover, the classification of the individual Nold and MCI subjects, with this tool, could reach a sensitivity of 95.87% and a specificity of 91.06% (93.46% accuracy)70,71 . ANNs could be a worthy tool to improve screening of high-risk population one day.
CONCLUSION Doubtless the only approach to trace a narrow line between physiological and pathological ageing is integrating genetic, biological, structural and functional variables. The latter change early, so measurement of functional variables could be helpful for early diagnosis. Neurophysiological tools that are low cost, non-invasive and widespread could be useful for large-scale screening and follow-up of populations at high risk of developing dementia. One of the most exciting challenges is to improve them.
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40. Steriade M, Llinas RR. The functional states of the thalamus and the associated neuronal interplay. Physiol Rev 1988; 68(3): 649–742. 41. Pfurtscheller G, Lopez da Silva F. Event-related EEG/MEG synchronization and desynchronization: basic principles. Clin Neurophysiol 1999; 110: 1842–57. 42. Sarter M, Bruno JP. Cortical acetylcholine, reality distortion, schizophrenia, and Lewy Body Dementia: too much or too little cortical acetylcholine? Brain Cogn 1998; 38(3): 297–316. 43. Hartikainen P, Soininen H, Partanen J, Helkala EL, Riekkinen P. Aging and spectral analysis of EEG in normal subjects: a link to memory and CSF AChE. Acta Neurol Scand 1992; 86(2): 148–55. 44. Dierks T, Jelic V, Pascual-Marqui RD et al . Spatial pattern of cerebral glucose metabolism (PET) correlates with localization of intracerebral EEG-generators in Alzheimer’s disease. Clin Neurophysiol 2000; 111(10): 1817–24. 45. Ponomareva NV, Selesneva ND, Jarikov GA. EEG alterations in subjects at high familial risk for Alzheimer’s disease. Neuropsychobiology 2003; 48(3): 152–9. 46. Babiloni C, Binetti G, Cassetta E et al . Mapping distributed sources of cortical rhythms in mild Alzheimer’s disease: a multicentric EEG study. Neuroimage 2004; 22(1): 57–67. 47. Prichep LS. Use of normative databases and statistical methods in demonstrating clinical utility of QEEG: importance and cautions. Clin EEG Neurosci 2005; 36(2): 82–7. 48. Sloan EP, Fenton GW, Kennedy NS, MacLennan JM. Electroencephalography and single photon emission computed tomography in dementia: a comparative study. Psychol Med 1995; 25(3): 631–8. 49. Rodriguez G, Nobili F, Copello F et al . 99mTc-HMPAO regional cerebral blood flow and quantitative electroencephalography in Alzheimer’s disease: a correlative study. J Nucl Med 1999; 40(4): 522–9. 50. Fernandez A, Arrazola J, Maestu F et al . Correlations of hippocampal atrophy and focal low-frequency magnetic activity in Alzheimer disease: volumetric MR imagingmagnetoencephalographic study. AJNR Am J Neuroradiol 2003; 24(3): 481–7. 51. Osipova D, Ahveninen J, Jensen O, Ylikoski A, Pekkonen E. Altered generation of spontaneous oscillations in Alzheimer’s disease. Neuroimage 2005; 27(4): 835–41. 52. Jelic V, Julin P, Shigeta M et al. Apolipoprotein E epsilon4 allele decreases functional connectivity in Alzheimer’s disease as measured by EEG coherence. J Neurol Neurosurg Psychiatr 1997; 63(1): 59–65. 53. Locatelli T, Cursi M, Liberati D, Franceschi M, Comi G. EEG coherence in Alzheimer’s disease. Electroencephalogr Clin Neurophysiol 1998; 106(3): 229–37. 54. Wada Y, Nanbu Y, Koshino Y, Yamaguchi N, Hashimoto T. Reduced interhemispheric EEG coherence in Alzheimer disease: analysis during rest and photic stimulation. Alzheimer Dis Assoc Disord 1998; 12(3): 175–81. 55. Knott V, Mohr E, Mahoney C, Ilivitsky V. Electroencephalographic coherence in Alzheimer’s disease: comparisons with a control group and population norms. J Geriatr Psychiatry Neurol 2000; 13(1): 1–8. 56. Adler G, Brassen S, Jajcevic A. EEG coherence in Alzheimer’s dementia. J Neural Transm 2003; 110(9): 1051–8.
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Potential Regeneration of the Ageing Brain Stephen B. Dunnett School of Biosciences, Cardiff University, UK
The brain does not spontaneously regenerate. As long ago as 1928, Cajal recorded that ‘once development was ended, the founts of growth and regeneration of axons and dendrites dried up irrevocably. In adult centres . . . everything may die, nothing may be regenerated’1 . Although it remains the case that the damaged mammalian central nervous system (CNS) does not in general generate new nerve cells in response to disease or injury, the intervening 70 years have identified a considerable plasticity of axons to remodel nerve connections and a limited degree of neurogenesis that opens new opportunities for promoting regeneration and repair in the damaged, diseased or ageing nervous system (see Figure 7.1).
ADAPTIVE PLASTICITY Even if lost cells are not replaced, spared neurons and fibres retain a considerable degree of plasticity to adapt to lost connections by adaptive biochemical compensation both at the presynaptic level – for example by changes in cell firing, transmitter synthesis, release and reuptake – and postsynaptically, by changes in receptor density, receptor sensitivity and post-synaptic signalling (Figure 7.1C)2,3 .
COLLATERAL SPROUTING The first clear evidence that Cajal’s dictum was overly pessimistic in relation to the mammalian CNS came from the demonstration that if a septal cell loses some of its normal axonal inputs then other afferent axons can sprout into the vacated spaces to form new synaptic connections with the target cell4 . If the new inputs are from a different source they are by and large not functional. However, collateral sprouting of spared fibres of the same systems do appear to be able to sustain functional recovery in a number of model circuits of the brain (Figure 7.1D)3,5,6 .
REGENERATIVE SPROUTING A major problem for extensive axonal reorganization in the adult brain is that although axons can undergo a degree of local sprouting, they do not typically retain the developmental capacity for longdistance growth through the CNS to distant targets (Figure 7.1E)3,7 . Long-distance growth of axons can nevertheless be promoted by providing an alternative substrate for growth such as Schwann cells from the peripheral nervous system (PNS) which can be used to bridge a
gap caused by a lesion cutting a pathway, or be implanted as a track along which new axons can grow (Figure 7.1H)8 .
NEURAL TRANSPLANTATION When essential populations of neurones are lost they may be replaced by transplantation. The techniques are now well established for transplantation of embryonic cells derived from the CNS into the brain of adult or aged experimental animals (Figure 7.1G), and such grafts have been demonstrated to survive, repopulate areas of denervation, replace deficient innervations, and restore lost functions in a wide variety of model systems9,10 . There is now compelling clinical evidence that such grafts can provide a substantial alleviation of symptoms in Parkinson’s disease11 , and clinical trials are now underway in Huntington’s disease, spinal cord injury and stroke12 – 14 . It remains a matter of speculation whether neuronal transplantation can alleviate the more diffuse and widespread degeneration associated with ageing and the dementias.
TROPHIC SUPPORT Neuronal connections are dependent upon trophic support from their targets, and neurodegenerative diseases of ageing may in part be attributable to a decline in growth factor support15 . Thus, an alternative approach to prevention of progressive neurodegeneration, and to induction and guidance of regenerative axon growth, is to apply or replace identified trophic factors explicitly. For example, dopaminergic neurones, which decline in several neurodegenerative diseases of ageing, are dependent upon trophic factors (including brain-derived neurotrophic factor (BDNF) and glial cell-derived neurotrophic factor (GDNF)) for trophic support. Chronic infusion of GDNF into the striatum or midbrain can inhibit progressive lesion and age-related atrophy of midbrain dopamine neurones and block the functional decline in motor abilities (Figure 7.1F) both in experimental animals16 and in man17 . A similar strategy involving chronic central infusions of nerve growth factor (NGF) has been attempted in a pilot experiment in Alzheimer’s disease with only modest success18 . A major issue to be resolved is how to deliver large trophic factor molecules – which do not cross the blood–brain barrier – to defined targets in the brain; the most powerful experimental techniques to date involve either implantation of cells that are engineered to secrete the particular trophic factor molecule (Figure 7.1G)19 or direct in vivo gene transfer (Figure 7.1F)20,21 .
Principles and Practice of Geriatric Psychiatry, 3rd edn. Edited by Mohammed T. Abou-Saleh, Cornelius Katona and Anand Kumar 2011 John Wiley & Sons, Ltd
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Figure 7.1 Schematic illustration of examples of regeneration and repair in the nigrostriatal system of rats A. Normal dopaminergic projections to the striatum arising from dopamine neurons in the ventral mesencephalon. B. Toxin 6-OHDA injections into the nigrostriatal pathway deplete striatal dopamine, typically more extensively in the dorsal neostriatum than in the ventral striatum. C. Compensatory adaptation of striatal receptors and biochemical turnover from residual spared. D. Compensatory collateral sprouting of ventral afferents following complete lesions of dorsal striatum. E. Long-distance regenerative axon growth from ventral mesencephalon typically is not a feature of nigrostriatal damage. F. Chronic delivery of growth factors such as GDNF by infusion or in vivo gene transfer can protect damaged axons and promote axon regeneration within the neostriatum. G. Implantation of ventral mesencephalic cells can restore dopaminergic innervation of the denervated striatum. H. Implantation of bridge grafts, e.g. of GDNF-secreting glial cells, can provide a substrate for long-distance axon regrowth from the ventral mesencephalon. I. Although adult neuron stem cells in the subventricular zone can provide functional cell replacement in dentate gyrus and olfactory bulb, evidence for a similar capacity for cell replacement in the striatum or ventral mesencephalon is weak
ADULT NEUROGENESIS It was believed until recently that all neurones of the mature nervous system are born in early development so that once lost they are not replaced. It is now clear that there exists in the adult human brain a small population of resting ‘neuronal stem cells’ with the capacity both to undergo further cell division and to differentiate into both neurones and glia22 . This opens the hope that such cells may be recruited for repair, either by isolation, expansion and differentiation into defined neuronal cell types in vitro, and reimplantation, or by finding the means to induce their spontaneous division, migration to areas of cell loss, and local differentiation into appropriate neuronal phenotype to replace lost target cells in vivo (Figure 7.1I). However, claims that endogenous adult stem cells can underlie recovery of function in the adult brain remain largely unsubstantiated, and substantial technical and theoretical problems remain in translating such procedures into applications for repair in human ageing.
CONCLUSION Although the repair of neuronal damage associated with neurodegenerative disease and normal ageing remains experimental, rapid advances are being made in the techniques for inhibiting degeneration, promoting regenerative growth and replacing lost populations of cells. The pessimism that has for long surrounded the poor prognosis of brain damage in ageing and disease is being transformed to an optimism that these novel experimental approaches may find direct
clinical application in the neurodegenerative diseases of ageing. Nevertheless, formidable technical problems still need to be overcome to transform theoretical prospects into practical therapies.
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delayed degeneration of nigral dopaminergic neurons following striatal 6-hydroxydopamine lesion. Proc Natl Acad Sci USA 1995; 92(19): 8935–9. Gill SS, Patel NK, Hotton GR, O’Sullivan K, McCarter R, Bunnage M et al. Direct brain infusion of glial cell line-derived nmeurotrophic factor (GDNF) in Parkinson’s disease. Nat Med 2003; 9(5): 589–95. ˚ Nordberg A, von Holst H, B¨ackman L, Ebendal T, Seiger A, Alafuzoff I et al. Intracranial infusion of purified nerve growth factor to an Alzheimer patient: the first attempt of a possible future treatment strategy. Behav Brain Res 1993; 57: 255–61. Nakao N, Yokote H, Nakai K, Itakura T. Promotion of survival and regeneration of nigral dopamine neurons in a rat model of Parkinson’s disease after implantation of embryonal carcinomaderived neurons genetically engineered to produce glial cell line-derived neurotrophic factor. J Neurosurg 2000; 92(4): 659–70. Martinez-Serrano A, Fischer W, S¨oderstr¨om S, Ebendal T, Bj¨orklund A. Long-term functional recovery from age-induced spatial memory impairments by nerve growth factor gene transfer to the rat basal forebrain. Proc Natl Acad Sci USA 1996; 93(13): 6355–60. Kirik D, Rosenblad C, Bj¨orklund A. Preservation of a functional nigrostriatal dopamine pathway by GDNF in the intrastriatal 6OHDA lesion model depends on the site of administration of the trophic factor. Eur J Neurosci 2000; 12(11): 3871–82. Eriksson PS, Perfilieva E, Bj¨ork-Eriksson T, Alborn AM, Nordborg C, Peterson DA et al. Neurogenesis in the adult human hippocampus. Nat Med 1998; 4(11): 1313–17.
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Neuroendocrinology of Ageing Marcus Simmgen Thomas Addison Unit, St George’s Hospital NHS Trust, Blackshaw Road, Tooting, London, UK
INTRODUCTION The subject of neuroendocrinology is the interface between the nervous and endocrine systems within the brain. Their structural and functional interaction is bi-directional; that is, neuronal activity modulates endocrine secretion and, in turn, hormones influence brain function. Both neurons and endocrine cells transmit signals to distinct target cells by releasing a chemical mediator that is recognized by specific receptors. There is overlap, as some secreted substances serve as both neurotransmitter and hormone, for example arginine vasopressin (AVP, also called antidiuretic hormone, ADH) or vasoactive intestinal peptide (VIP). Virtually all neurotransmitting systems are involved in the neuroendocrine interaction, and jointly they regulate metabolic homeostasis, growth, development and reproductive function and they influence behaviour, learning, emotional and mental state. Within the brain, the anatomical sites of closest interaction between the two systems are the hypothalamic-pituitary unit and the pineal gland. Peripherally, endocrine secretion is controlled either by direct innervation through autonomic secretomotor fibres or, indirectly, through the regulation of blood flow. The endocrine effects on the CNS are widespread: the limbic system structures of hippocampus, amygdala, hypothalamus and cingulate gyrus, as well as the pre-frontal cortex and various other parts of the brain, are responsive to endocrine signals that may alter their morphology or functional behaviour. The neuroendocrine interface is also linked closely to the body’s immunological responses, and the increasingly complex interactions have been described as a neuroendocrine-immune network. Significant immunological changes occur during the ageing process, in part as a consequence of these interactions; however, these aspects are beyond the scope of this chapter. As in other regions of the brain, the number and function of certain hypothalamic neurons and neuroendocrine cells declines during senescence, while other cell populations remain intact or even hypertrophy1,2 . Circadian rhythms of secretion undergo a phase shift or become less pronounced and increasingly irregular3 . Some endocrine axes undergo a significant physiological decline in their activity as a consequence of altered central regulation, loss of peripheral endocrine secretory capacity, tissue responsiveness or post-receptor signalling changes. While the menopause is an established life event for women, the effects of the gradual decline of male sex hormone levels (sometimes termed ‘andropause’),
of adrenal androgen production (‘adrenopause’) and of growth hormone (‘somatopause’) on healthy ageing are still the subjects of ongoing debate and research. In senescence, there are changes in body composition, loss of muscle strength, reduction in endurance and frequently a decline in cognitive, emotional and psychological function. Various hormonal changes contribute to these developments, and the chapter is arranged by endocrine axis and peripheral hormone. A brief overview of its physiology and CNS-related regulation is followed by a description of the changes occurring during senescence, and the implications for the ageing person.
ADENOHYPOPHYSIS The anterior, glandular lobe of the pituitary gland is derived from pharyngeal ectoderm rather than from neuroectoderm. It achieves a close functional relationship with its regulatory neurons through the capillary portal circulation that exists between the median eminence of the hypothalamus and the adenohypophysis. Releasing and inhibiting hormones thus reach the anterior pituitary gland to exert control over its secretion of hormones with a tropism for the peripheral endocrine glands. All anterior pituitary hormones are released in a pulsatile manner. While they provide feedback inhibition at hypothalamic neurons (short loop), the peripheral hormones exert negative feedback at pituitary and hypothalamic level to ensure stable plasma levels (long loop). The pituitary generally reduces in size during senescence4 .
Somatopause Growth hormone is synthesized by the somatotroph cell population of the anterior pituitary gland and released in pulsatile bursts with a peak after the onset of sleep. Two hormones are known to stimulate growth hormone synthesis and secretion: growth hormone-releasing hormone (GHRH) and ghrelin, both of which are produced in the hypothalamic arcuate nucleus. The former acts via its cognate GHRH receptor (GHRHR), and the latter via the growth hormone secretagogue receptor (GHSR). In addition, a range of other factors exert control over growth hormone release; such as metabolic substrates, physiological stimuli (sleep, exercise or stress) and certain neurotransmitters. Somatostatin, a hormone produced in the hypothalamic anterior paraventricular nucleus (PVN) inhibits growth hormone release, and the overall output effectively reflects an integration of all these stimuli.
Principles and Practice of Geriatric Psychiatry, 3rd edn. Edited by Mohammed T. Abou-Saleh, Cornelius Katona and Anand Kumar 2011 John Wiley & Sons, Ltd
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Under the influence of growth hormone, primarily the liver produces insulin-like growth factor 1 (IGF-1), which mediates many of the effects of growth hormone on target tissues. Metabolic effects of growth hormone are: increased muscle mass and strength, reduced fat mass, increased bone density and improved cholesterol levels5 . Growth hormone levels peak in adolescence and decline by 14% each decade, a process that is further accelerated in postmenopausal women. The amplitude of nocturnal growth hormone pulses falls and may disappear6 . Since physiological ageing is associated with an increase in body fat and a reduction in muscle mass, as well as with a fall in bone density, there are similarities with adult growth hormone deficiency, and the term ‘somatopause’ has been used for this. A trial of supplementary growth hormone in a cohort of ageing men showed significant improvement in these parameters7 . After 12 months of administration, however, side effects of carpal tunnel syndrome, gynaecomastia and hyperglycaemia became evident8 . A meta-analysis concluded that, while growth hormone replacement was beneficial in growth hormone deficiency, supplementation in an otherwise healthy elderly person showed no evidence for improvements in maximal oxygen consumption, bone mineral density, lipid levels and fasting glucose and insulin levels. There was no suggestion that growth hormone prolonged life. Since there is also a theoretical risk of increased neoplastic disease, there are no grounds to advocate growth hormone supplementation in healthy ageing5 . As an alternative, small molecules have been developed to act at the GHSR as a long-acting oral ghrelin analogue9 . One trial was reported after one year to have achieved enhanced growth hormone pulsatility, restored IGF-1 values to juvenile levels, increased fatfree body mass and marginally lowered LDL-cholesterol. Observed side effects were a mild increase in fasted glucose, insulin resistance, cortisol levels and a weight gain of 2.7 kg vs. 0.8 kg in the placebo group10 . Another compound improved lean body mass and functional strength, balance and coordination. Side effects were deterioration in parameters of insulin resistance, fatigue and insomnia11 . Neither drug has reached the market.
Prolactin Prolactin is structurally related to growth hormone, and its secretory regulation is unusual in that the pituitary lactotroph cells are under tonic inhibition by dopamine-producing hypothalamic neurons. Circulating prolactin levels comprise of a combination of basal and pulsatile release12 . Prolactin levels rise in response to sleep to peak in the early hours13 , and secretion is increased by stress and other stimuli. In men and non-pregnant women, prolactin concentrations gradually decline with advancing age. Frequent nocturnal sampling showed this to be a result of falling basal prolactin secretion that is associated with a reduced lactotroph cell mass or responsiveness, and also to be due to a reduction in hypothalamic stimuli for pulsatile bursts14 . In ageing rats, the circadian rhythm of prolactin secretion loses the ability to adapt to changes in the light–dark cycle15 . In a large observational study of a cohort of middle-aged men (52 ± 12.9 years) attending for sexual dysfunction, the lowest quartile of prolactin concentrations was associated with increased risk for metabolic syndrome, atherogenic erectile dysfunction, premature ejaculation and anxiety. There also is evidence for immunemodulating properties of prolactin since, in mice, prolactin deficiency caused impaired lymphocyte function by reducing cytokine-induced macrophage activation16 . However, the clinical relevance of reduced prolactin levels in senescence is unclear and no trials of replacement therapy in ageing humans have been conducted.
Menopause The female cycle is under complex regulation by luteinizing hormone (LH) and follicle-stimulating hormone (FSH), which are produced by the gonadotroph cell population of the anterior pituitary gland. Both are released in pulsatile fashion under control by hypothalamic gonadotrophin-releasing hormone (GnRH). In addition to the daily high-frequency pulsatility, their secretion is cyclical over the period of a lunar month. Complex feed-forward and feedback regulation between the hypothalamus, the pituitary gonadotroph cells and the ovary leads to the menstrual cycle during a woman’s fertile years. Oestrogen is produced mainly in the granulosa cells of the developing ovarian follicle from an androgenic precursor and is the main female sex steroid hormone. Follicular depletion, however, is not the sole reason for the menopause. Studies in rats demonstrated that prior to any cycle irregularities there was an early decline in GnRH-neuron response and a consequently reduced LH surge in response to oestrogen around the time of ovulation. Thus the functional loss begins centrally at the level of hypothalamus and pituitary which, together with the changes at ovarian level, leads to the menopause17 . With the loss of follicular activity, which usually occurs around the mid-sixth decade of life, a rapid fall of oestrogen levels ensues and FSH and LH levels rise due to absence of feedback inhibition. Consequences of a lack of oestrogen are manifold: Atrophy of oestrogen-responsive tissues, rapid loss of bone mass, adverse changes to the lipid profile with increased atherogenic risk, depressive mood swings, lack of concentration, anxiety and loss of libido. Vasomotor symptoms of hot flashes not only impair quality of life, but also represent altered blood vessel physiology that is associated with increased cardiovascular risk18 . Since the reduction in oestrogen leads to a narrowing of the ‘thermoneutral’ zone of temperature regulation in the hypothalamus, small changes in core body temperature can trigger symptoms19 . Oestrogen-containing hormone replacement therapy (HRT) can ameliorate vasogenic menopausal symptoms and delay biochemical changes. To avoid a concomitant excess risk of cardiovascular events, HRT should be taken early20 and for a limited period only to minimize the additional hazard of thromboembolism and breast cancer21 . Contrary to expectations, HRT in elderly women did not preserve cognitive ability but was associated with an increased risk of dementia and global cognitive decline that correlated with a reduction in hippocampal, frontal lobe and total brain volumes22 . It should be noted, however, that some of the noted CNS effects might be (i) specific to the hormone molecule used in the quoted studies, (ii) related to the late timing of HRT, and (iii) due to elevated levels of LH itself, rather than related to oestrogen deficiency23 .
Andropause Testosterone, the predominant male sex steroid hormone, is produced by testicular Leydig cells under the influence of LH and FSH. As in women, both gonadotrophins are released in pulses from the anterior pituitary gland under GnRH control. Testosterone levels in men follow a diurnal rhythm with peak concentrations occurring in the morning. At puberty, bioavailable testosterone levels begin to rise; they peak around the third decade of life and gradually fall thereafter at an annual rate of 1.3%24 . Circulating testosterone binds to sexhormone-binding globulin (SHBG) and, with less avidity, to albumin. Thus the availability of free testosterone reduces as SHBG levels rise
NORMAL AND ABNORMAL AGEING with age by 1.2% per annum. Leydig cell attrition, reduced steroid synthetic activity and a lower responsiveness to LH are the main testicular factors contributing to this decline25 . The circadian variation in testosterone also declines with age. The term ‘andropause’ has hence come into use as a male equivalent to the menopause, even though the decline in sex hormone levels is gradual in men compared to the relatively sudden reduction in women. Reduced testosterone availability exerts major metabolic effects on metabolism and thus lowers muscle mass and strength, raises body fat content and negatively affects bone health, libido and reproductive function, as well as mood and cognition26 . As in menopausal women, the elevation of LH has been implicated in the pathophysiology of Alzheimer’s disease in men, as low testosterone concentrations were correlated with increased amyloid-beta protein levels27 . While a significant proportion of ageing males over the age of 65 years have reduced levels of testosterone, there was wide variability within a large cohort of community-dwelling men and serum concentrations were a poor indicator of symptoms28,29 . A recent consensus statement therefore emphasized the need for correlation of clinical symptoms with testosterone levels, the lack of cardiovascular and bone fracture outcome data and the need for surveillance for prostate carcinoma, among others, in case of replacement therapy30 .
Thyroid Axis The hormones thyroxine (or tetra-iodo-thyronine, T4) and tri-iodothyronine (T3) are synthesized and secreted by thyroid follicular cells. Only a small proportion of T4 is converted to T3 prior to its release from the thyroid; almost all of the remainder undergoes monodeiodination in peripheral tissues. T3 has greater biological activity than T4 and a shorter half-life. Plasma levels of both hormones are regulated by thyroid-stimulating hormone (TSH, also called thyrotrophin) that is released by the thyrotroph cells of the anterior pituitary gland, which in turn are under hypothalamic thyrotrophinreleasing hormone (TRH) control. Virtually all tissues possess receptors for the thyroid hormones, through which the latter regulate the basal metabolic rate, tissue function, protein, fat and carbohydrate metabolism, as well as influence mental function and psychological well-being. The prevalence of thyroid autoantibodies significantly increases with age and, if primary thyroid dysfunction is present (subclinical or overt hypo- or hyperthyroidism), cognitive function is almost invariably affected31 . Such conditions clearly merit thyroid hormone replacement or suppressive therapy, respectively. In primary hypothyroidism, the pituitary thyrotroph cells appear to lose their responsiveness to low thyroid hormone levels, as the TSH response was significantly reduced at ages over 80 years32 . In a large, thyroid disease-free population, however, senescence per se led only to a minor increase in TSH levels, which remained well within the normal range33 .
Adrenocortical Axis The hypothalamic–pituitary–adrenal (HPA) axis is central to the adaptive stress response that follows an initial, catecholaminemediated ‘fight-or-flight’ reaction. Cortisol is released from the adrenal cortex following stimulation by adrenocorticotropic hormone (ACTH, also called corticotrophin), which is produced by the corticotroph cell population of the anterior pituitary gland. Corticotrophin-
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releasing hormone (CRH), from hypothalamic neurons residing in the PVN, regulates ACTH secretion in a diurnal pattern. Cortisol is the main glucocorticoid in humans. It induces insulin resistance and raises blood glucose levels, causes protein and bone catabolism and an elevation in blood pressure. It also dampens the immune response. While a short-term stress response is necessary to deal with the challenges to the body’s homeostasis, this reaction must itself be regulated. The hippocampus expresses glucocorticoid receptors and exerts inhibitory control over HPA axis activation, thus limiting the stress response36 . The physiological day-to-day stress adaptation has been termed ‘allostasis’34 , with its regulatory failure leading to an ‘allostatic load’35 . The hippocampus expresses glucocorticoid receptors and exerts inhibitory control over HPA axis activation, thus limiting the stress response36 . The adrenal capacity for cortisol production is not affected by ageing, although its circadian rhythm is blunted and basal activity increased37 . However, with advancing age the negative-feedback sensitivity reduces at hippocampal level and the HPA axis activity increases3 . In both sexes, mean cortisol levels increased by 20–50% between the ages of 20 and 80 years38 . Magnetic resonance imaging showed that the volumes of hippocampus and anterior cingulated gyrus were inversely correlated with baseline ACTH levels, and that older subjects demonstrated a slower decrease in ACTH in response to an infusion of cortisol than younger volunteers39 . The stressinduced remodelling of the hippocampus and the resulting rise in glucocorticoid levels thus increases the allostatic load, with negative results for a range of metabolic parameters and the immune system that is associated with ageing40 . Furthermore, the hippocampus and related limbic structures of the amygdala and pre-frontal cortex are of key importance for learning and memory function, including emotional learning and processing. Persistent elevation of glucocorticoid levels is involved in the emotional memory disturbances found in depression and posttraumatic stress disorder41 .
Adrenopause Dehydroepiandrosterone (DHEA) and its sulfate ester (DHEAS) are abundant androgenic steroid molecules that serve as precursor molecules for other androgens and oestrogen. DHEA is produced by the adrenal cortex and also serves as a neurosteroid42 . ACTH regulates its secretion and, in contrast to cortisol and aldosterone, DHEA levels physiologically decline with ageing from the third decade onwards by around 2% annually43,44 . At the age of 80 years, DHEA concentrations are approximately 20% of those of younger controls45 . Observational studies have associated low DHEA levels with cardiovascular disease, low bone density, type 2 diabetes, low mood and Alzheimer’s disease. However, no causal relationship has been established46 . DHEA replacement therapy is the focus of research for its potential anti-ageing properties in otherwise healthy older subjects. So far, however, no firm therapeutic indication has emerged43,47 .
NEUROHYPOPHYSIS The posterior, neural lobe of the pituitary gland contains axonal projections of neurons from the supraoptic (SON) and paraventricular (PVN) hypothalamic nuclei. Axoplasmic flow transports argininevasopressin (AVP) and oxytocin to the neurohypophysis for storage.
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The nuclei receive cholinergic and noradrenergic innervation and hormone secretion is triggered by a rise in plasma osmolality, reduction in circulating fluid volume, nausea, pain or emotional stress. While the AVP receptor V2 is mainly expressed in the kidney, V1a and V1b receptors are widely distributed within the brain48 .
Arginine-Vasopressin AVP is central to the maintenance of fluid and osmolality homeostasis throughout life. Basal AVP levels in men were higher in older subjects and showed less responsiveness to fluctuations in osmolality compared to young volunteers. Reduced satiation to water consumption after induction of thirst by infusion of hypertonic saline was demonstrated by altered blood flow in the anterior mid-cingulate cortex on positron emission tomography49 . The renal tubules become less responsive to AVP in ageing humans and rodents. In the rat, the reduced urine-concentrating ability was found to be due to a downregulation of the V2 receptor, while AVP levels remained normal50 . In addition to its function in fluid homeostasis, abnormal plasma AVP levels have been implicated in a range of mental disorders. Elevated concentrations of AVP have been noted in depression, posttraumatic stress disorder, acute schizophrenia and other mental illness48 . In depressed patients with Alzheimer’s disease, however, the content of AVP and oxytocin mRNA in SON and PVN was unchanged compared to controls, and there was no correlation with depression51 . In rodent models and (confirmed in part) in humans, AVP has also been determined to modify memory and social behaviour such as aggression and affiliation52 .
Oxytocin Oxytocin plays no significant physiological role in senescence. Basal levels and the response to hypoglycaemia-induced stress remained comparable in older compared to young men53 .
PINEAL GLAND The pineal gland is situated within the roof of the third ventricle above the Sylvian aqueduct. In fish and amphibians the equivalent structure is light sensitive, whereas in humans the pineal gland receives input from the hypothalamic suprachiasmatic nucleus (SCN) that, in turn, is connected to the retina via non-visual photosensitive pathways. The SCN functions as the master clock for circadian rhythmic activity, which is further entrained by external zeitgebers.
Melatonin The pineal gland synthesizes and secretes melatonin predominantly during periods of darkness and thus conveys a biological diurnal rhythm as well as an annual seasonal rhythm to the body. While daytime melatonin production remains virtually unchanged throughout life, nocturnal secretion of melatonin peaks in early childhood and thereafter continuously declines with age. After the age of 60 years, peak peripheral night-time melatonin concentrations fall to 40 pg/ml, compared to 160 pg/ml at the age of 10 years. Background daytime levels are in the order of 30 pg/ml54 . The SCN and the hypothalamus express a high density of MT1 receptors, allowing for chronobiological feedback to the central clock. In senescence, the circadian rhythm becomes weaker, sleep
disturbances more common and there is an associated increasingly irregular diurnal melatonin secretion. The reduced number and density of MT1 receptor-expressing neurons that was found in the SCN of older subjects compared to young controls can, in part, explain this. In the last stages of Alzheimer’s disease the prevalence of these neurons was further reduced55 . Melatonin has non-sedative sleep-inducing properties, and trials of prolonged-release melatonin administration to patients with insomnia aged 55 years and older have shown to improve sleep quality, morning alertness and psychomotor performance. The supplement was administered for three weeks and no withdrawal or rebound symptoms were observed56,57 .
CONCLUSION Complex neuroendocrinological changes occur during the healthy ageing process at hypothalamic, hypophyseal and target endocrine tissue level. There is increasing evidence that altered neuronal function with irregularities in biological rhythm and decreased secretory responsiveness leads to the significant reduction in availability of several peripheral hormones3 . Declining levels of sex steroids, growth hormone, adrenal androgens and melatonin secretion contribute to significant adverse changes in body composition and endurance, cardiovascular risk profile, bone strength, sexual physiology, circadian rhythms, cognition and emotional and psychological well-being. Attempts at restoring youthfulness through the replacement of physiologically declining hormones have so far concentrated on time-limited, perimenopausal therapy with low-dose oestrogen. However, promising molecules to improve the growth hormone axis and the melatonin -mediated sleep–wake cycle are being tested. As senescence is a multifactorial process in which other morbidities and drug therapy frequently play a major part, any neuroendocrine changes should naturally not be viewed in isolation. Furthermore, whether a physiological change in life is perceived as being pathological and warranting treatment must be considered within the individual’s social, environmental and lifestyle context. An optimistic outlook has the potential to prolong life considerably58 .
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mRNA expression in relation to depressive state in Alzheimer’s disease: a difference with major depressive disorder. J Neuroendocrinol 2009; 21(8): 722–9. Caldwell HK, Lee HJ, Macbeth AH, Young WS 3rd. Vasopressin: behavioral roles of an “original” neuropeptide. Prog Neurobiol 2008; 84(1): 1–24. Chiodera P, Volpi R, Capretti L et al. Oxytocin response to challenging stimuli in elderly men. Regul Pept 1994; 51(2): 169–76. Karasek M. Does melatonin play a role in aging processes? J Physiol Pharmacol 2007; 58 (Suppl 6): 105–13. Wu YH, Zhou JN, Van Heerikhuize J, Jockers R, Swaab DF. Decreased MT1 melatonin receptor expression in the suprachiasmatic nucleus in aging and Alzheimer’s disease. Neurobiol Aging 2007; 28(8): 1239–47. Luthringer R, Muzet M, Zisapel N, Staner L. The effect of prolonged-release melatonin on sleep measures and psychomotor performance in elderly patients with insomnia. Int Clin Psychopharmacol 2009; 24(5): 239–49. Lemoine P, Nir T, Laudon M, Zisapel N. Prolonged-release melatonin improves sleep quality and morning alertness in insomnia patients aged 55 years and older and has no withdrawal effects. J Sleep Res 2007; 16(4): 372–80. Levy BR, Slade MD, Kunkel SR, Kasl SV. Longevity increased by positive self-perceptions of aging. J Pers Soc Psychol 2002; 83(2): 261–70.
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Genetic Aspects of Ageing Ben Pickard1 and Douglas Blackwood2 1 Strathclyde
Institute of Pharmacy and Biomedical Sciences (SIPBS), University of Strathclyde, UK 2 Division of Psychiatry, University of Edinburgh, UK
INTRODUCTION: LIVING LONGER VERSUS CHEATING DEATH That there may be specific biological processes determining life span is an intriguing concept, and one which has attracted interest from both the academic and commercial sectors. Such interest has often focused on the simple numerical indicator of life span but this can often be at odds with the clinical perspective that centres on quality of life for the elderly. In this chapter we will review the latest findings and current ideas in the fields studying the biological process of ageing, its evolutionary underpinning and the genetic factors intertwined with environmental exposure that determine our life span. There is also a semantic issue of whether a discussion of ageing should include factors contributing to longevity if they merely afford protection against the dominant degenerative disorders or serious illnesses of the elderly or only concentrate on mechanisms that actively delay the ageing process1 . Plainly, these two aspects of ageing are inextricably linked but from a research point of view, and in the context of genetic models, only the latter offers fundamental insights into the process.
AGEING GENETICS, HERITABILITY AND EVOLUTIONARY INFLUENCES Danish epidemiological studies have reported that the heritability of human longevity is approximately 25%2,3 : a figure similar to that for lower organisms. Thus there exists scope for the genetic dissection of the phenotype and a substrate for the processes of evolution to act on4 . In its purest form, evolution requires that advantageous genetic variation is favoured and increases its frequency in the population through the process of natural selection. This is mediated through its ability to increase a carrier individual organism’s ‘fitness’ and thus its ability to reproduce at a greater than average level. It can be appreciated that this raises fundamental conceptual issues in the context of the genetics of longevity. Female reproductive fitness, in particular, occupies only a proportion of the modern human life span and so it could be hypothesized that gene variants influencing life span in the age range from 55–85 years would be under minimal selection compared to those dictating survival within the 15–45-year age range. It has also been argued that, for some species, individuals living beyond reproductive age are counterproductive to species survival – they are a drain on limited resources and thus compete with actively reproducing individuals. Selection pressure for a
biologically programmed ‘cap’ on life span might avoid this conflict. A second argument against a clear genetic contribution to human longevity would be the vast period of human existence on Earth for which 45 years was ‘old age’. In the case of humans, long life spans are a modern phenomenon – average life expectancy dropped in the transition from ‘hunter-gatherer’ (Mesolithic Stone Age) to agrarian (Neolithic Stone Age) lifestyles5 and did not significantly exceed the median life span of approximately 30–35 years until recent centuries. The implications are that not only does a long life harm fellow members of one’s species, it also has no evolutionary outlet in the form of increased reproductive fitness. The genetics of ageing is left evolutionarily ‘rudderless’ in these circumstances. However, two hypotheses offer an alternative view, supporting an evolutionarily ‘visible’ role for ageing. Firstly, the adoption of agriculture inevitably led to community living and increased social complexity. These social organization developments might be manifest in the altruistic role of the elderly in supporting the community – perhaps through leadership, childcare or other division of labour favourable for group survival. The impact of cultural effects (a form of environment) on ageing can never be entirely separated from genetics in the study of ageing in particular and will be covered in more detail below. Secondly, and perhaps more biologically tractable, is the argument that the genetic variants altering later life survival also play a role in earlier life fitness and are thus relevant to reproductive potential. Finally, it is also worth considering the corollary of the sudden upturn in life span in recent human history – it has exposed humans to the consequences of genotypes that were never previously expressed for so long. For example, gene variants increasing susceptibility to Alzheimer’s disease might be the result of random mutational drift or positive selection for their benefit in the young, but it is only now that they have been exposed to the environment of the ageing brain and consequently deemed pathological.
AGEING BIOLOGY: CLUES FROM HUMAN SYNDROMES The fact that well-characterized human disorders of premature ageing (progeria) exist suggests that there are real biological processes at work, and ones which are tractable to genetics research. Individuals with progeroid disorders present with a spectrum of phenotypes which closely resemble natural ageing but these occur in young
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adulthood or even childhood. A multitude of mutations in two particular genes, WRN and LMNA, account for the majority of these cases. Werner syndrome (WS) is perhaps the best studied of these and is caused by mutations in the WRN gene which encodes a helicase/exonuclease protein that functions during the critical processes of active nuclear DNA functioning such as replication, recombination and repair – when potentially pathological errors can be introduced into our DNA. Thus, the consequences to genomic integrity in WS patients are an accelerated version of those hypothesized to occur in normal individuals as a result of a lifetime of environmental exposure and mutation accumulation. The phenotypes are similar too, ranging from osteoporosis, cataracts, type II diabetes, atherosclerosis and cancers (particularly mesenchymal sarcomas) such that WS patients tend to die in their 50s as a result of complications arising from these conditions. Interestingly, the phenotypic spectrum of WS doesn’t seem to include the neurodegenerative conditions such as Alzheimer’s disease. It is tempting to speculate that these particular disorders are due to the accumulation of protein aggregates (plaques and tangles), i.e., protein attrition rather than genomic DNA attrition. Mutations in the lamin A gene, LMNA, encoding a nuclear intermediate filament protein involved in the packaging of nuclear chromatin, cause ‘atypical’ WS, or in extreme cases involving a particular LMNA splice mutation, the severe and very early-onset Hutchinson–Gilford progeria syndrome (HGPS). A number of other rare progeroid syndromes exist and, of these, Cockayne syndrome type 1 (CS) is the only other one discussed here. This is caused by mutations in the transcription-coupled nucleotide excision repair genes, CSA and CSB, which also contribute to the cell’s battle against genomic damage. The genes emerging from these human conditions unequivocally point to the maintenance of genomic integrity as a vital process in ageing, involving the concerted action of several different systems to achieve it. Mutations in these systems seem to result in either progerias or cancer syndromes, or occasionally both (e.g. WS). It has been suggested that these alternative outcomes result from the specific responses to DNA damage initiated by the various systems: repair, apoptosis or senescence6 .
AGEING BIOLOGY: CLUES FROM LOWER ORGANISMS The validity of certain mouse models of ageing has sometimes been questioned for the very reasons discussed previously – distinguishing genuine progeroid features from a numerically shorter life span due to pathological state7 . Therefore, the presence of features such as kyphosis, as an indicator of an osteoporotic state, stereotypical fat deposition and atrophy of the epidermis are often employed as benchmarks of true ageing models. The progeroid conditions in humans point towards accumulating DNA damage as a mechanism of ageing and the increased life span of mice over-expressing the antioxidizing protein thioredoxin seems to confirm the importance of this process. However, other transgenic mouse models with modulated life spans suggest that additional contributory mechanisms are at play. Historically, it has been suggested that cellular, organ and organismal ageing are affected by the rate of cell proliferation and apoptosis. This has manifest itself in such concepts as the Hayflick limit8 whereby oxygen levels encountered and cell divisions undergone are recorded by each cell using the gradual shortening of the telomere sequences located at the ends of chromosomes as an internal clock. At a defined telomere threshold length the cell enters a state of protective
self-induced senescence, thus reducing the potential for DNA damage to be manifest as oncogenic cellular changes. Indeed, a number of mouse mutations linked with altered life span involve proteins that can be classified as regulators of mitosis and cellular proliferation (e.g. p53, Brca1 and p21WAF1 ) and these have been reviewed elsewhere9 . Alternatively, other mouse models centre on the signalling pathways modulating and modulated by growth hormone, insulin and insulin-like growth factor such as the Ames dwarf and Laron mouse strains. Mice deficient for the Klotho gene product, encoding a hormone that inhibits the action of the insulin/IGF-1 pathway, show a progeria phenotype whereas Klotho over-expressing mice are longer lived. Finally, SIRT1 , a member of the sirtuin class of genes, downregulates the production of insulin and IGF-1 thus promoting increased life span. These mouse models, particularly the dwarf strains, and other observations point to a correlation between longevity and body size within a species. It has been reported that shorter humans have on average a greater life span – this is even despite the observation that taller individuals are generally protected against atherosclerosis. The speculation is that body size is closely related to ‘cellularity’, or the number of divisions during the growth process. This in turn is a reflection of the proliferative potential of an individual’s cells as discussed above. The correlation is clearly not a simple one as those with progeroid syndromes are often of short stature. Moreover, the role of the growth hormone/insulin pathway in aspects of cell proliferation, growth, DNA repair and caloric intake (discussed below) means that these processes are all interconnected at some level in their contribution to the rate of ageing. Naturally, many mouse strains deficient in aspects of genomic repair have been generated given the seeming importance of this process in ageing. One intriguing and counterintuitive result comes from the study of Csb, Xpa and Ercc1 mouse mutants and combinations thereof. These mice show definitive progeroid symptoms but also display a downregulation of the insulin/IGF-1 signalling pathway. Normally, such downregulation is protective and life prolonging as discussed in detail below, but in these instances it appears to be an innate compensatory mechanism responding to increased levels of genome instability. It may be the case that ageing is such a fundamental property of life or the environmental insults so similar that organisms from across all taxa have adopted the same molecular machinery to counter it. In this way there are a growing number of studies which seek to address human ageing through the study of yeast, nematode worm and fruit fly in addition to the mouse. McCarroll et al. pursued this approach to the genetics of ageing by employing cross-species profiling of gene expression changes correlated with age10 . What they observed was a shared set of age-responsive gene expression changes between the nematode C. elegans and the fruit fly D. melanogaster. Genes involved in oxidative metabolism (such as respiratory chain proteins, ATP synthase and citric acid cycle proteins) and active molecular transport were significantly reduced with age. However, the timing of these changes suggested that this was part of an active programme rather than solely a response to environmental attrition. For instance, in both species, experimentally reducing oxidative stress had the greatest effect on life-span extension during early adulthood. Conversely, modulating the insulin/IGF-1 system had a more pronounced effect on life span in the middle-aged organism. We can interpret these findings to mean that the body has set in place metabolic strategies to pre-empt and minimize the damage associated with ageing. As the authors suggest, a greater appreciation of human health-affecting behaviour in early adulthood might yield benefits in later life.
NORMAL AND ABNORMAL AGEING The same laboratory pursued the role of the insulin/IGF-1 and daf2 (insulin/IGF-1 receptor) pathway that was already known to affect life span in C. elegans 11 . Using mutant strains and RNAi methodologies, they showed through microarray screens that the FOXO transcription factor daf-16 is required to mediate this signalling pathway: daf-2 deficiency releases daf-16 from repression and allows it to activate its downstream target genes. Interestingly, the insulin/IGF1 signalling system has close parallels in mammals – a mammalian orthologue of daf-16 exists, FOXO3A, that is regulated by the IGF-1 pathway effector and ageing gene, p66SHC . In the C. elegans experiment, sets of daf-16 upregulated and downregulated genes were identified in longer living mutant strains. In the former group, the genes encoding for stress response and antioxidant genes such as superoxide dismutase 3 and a metallothionein gene were identified together with lipid hormone metabolism and antimicrobial genes. In mammals, FOXO3A seems to additionally upregulate components of the genome maintenance pathway. In the latter, downregulated, group of genes were examples of metabolic genes, ubiquitination genes and genes of the vitellogenin structural egg yolk protein group. In the light of the earlier discussion regarding whether longevity is the result of active life extension or avoidance of death, it is interesting to see examples of both mechanisms (antioxidant/metabolic inhibition vs. antimicrobial) represented in the gene lists.
REACTIVE OXYGEN SPECIES, CELLULAR DAMAGE AND GENETICS The damage to DNA and other cell macromolecules is caused by the reactive oxygen species (ROS) produced as a result of the energy-generating oxidative phosphorylation occurring within the mitochondria in each of our cells12 – a small proportion of the oxygen consumed in this process is released as reactive superoxide species. Because mitochondria themselves possess a genome (encoding some of the components of the oxidative phosphorylation machinery) located near the source of the ROS, it has been suggested that it is very likely to be subject to high levels of damage (mutation accumulation) as the organism ages. Mitochondrial mutations would potentially cause feed-forward degeneration: a reduction in oxidative phosphorylation efficiency causing an increase in ROS production and, therefore, further propensity for cellular damage. Ageing not only results in the accumulation of mutations in the mitochondrial genome but it also permits the mutated genomes to accumulate within each cell (each cell has anywhere between 10s and 100s of mitochondrial genomes). At some point, a threshold will be crossed where the accumulating mitochondrial deficits impinge on cell function – and it can be appreciated that if such cells are part of the proliferating stem cell niche then either the dissemination of the deficit could be accelerated within a tissue or the proliferation process inhibited by the reduction in oxidative phosphorylation leading to a decrease in tissue regeneration13 . It is now well documented that multiple organ systems are compromised by mitochondrial failure14 . Perhaps due to their high energy demands, the central and peripheral nervous systems appear particularly susceptible to mitochondrial dysfunction which manifests itself in the form of neuropathies and dementia. Nevertheless, pathologies of the heart, lungs, musculature, pancreas and thymus have also been linked to mitochondrial failure in humans. Two studies have shown particularly clear age-dependent accumulation of definitively pathological mitochondrial mutations in the substantia nigra – a region of the brain implicated in the aetiology of Parkinson’s disease in the elderly. The causal link with
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illness is not straightforward, however, as the mutation prevalence appears to be equal in aged individuals with or without Parkinson’s disease15,16 . Mitochondria, like nuclei, have dedicated mechanisms for repairing damaged DNA and thus mouse models have been generated that lack one of the repair proteins encoded by the Polg1 gene. These mice have greatly increased levels of mitochondrial mutations and show a decreased life span associated with typical ageing phenotypes such as osteoporosis and weight loss17,18 .
A GENE–ENVIRONMENT INTERACTION BETWEEN CALORIC INTAKE RESTRICTION AND LONGEVITY A longstanding direction for ageing research is based on the observation that a reduction in caloric intake results in not only an increase in life span but also an increase in general health including a reduction in illnesses of old age19 . These studies seem to hold true across a wide range of species from yeast, C. elegans and D. melanogaster through to mouse and monkey. In terms of reproductive fitness, however, dietary restriction actually reduces fecundity. This suggests that variants leading to reduction in food uptake or slowed metabolism are unlikely to be favoured by genetic selection processes as they will be outcompeted by variants promoting an ‘eat fast–die young’ strategy that produces greater numbers of offspring. Dietary restriction seems to exert its effect on life span through a number of mechanisms. These can be essentially divided into two classes: those that alter intracellular pathways governing metabolism and survival and those that counteract the production of the harmful reactive oxygen species that are a byproduct of the oxidative phosphorylation pathway20 . As detailed earlier, metabolic control through the insulin and insulin-like growth factor pathway is implicated in ageing and this is highlighted by its role in the response to dietary restriction. In times of freely available nutrition, insulin signalling results in the phosphorylation and subsequent degradation of Forkhead transcription factors (daf-16 in C. elegans and FOXO3A in mammals). However, when food is limited, these transcription factors are able to enter the nucleus where they activate a set of genes which are thought to mediate a change in organismal strategy geared towards survival or even hibernation-like states. New insights from C. elegans are rapidly filling in the gaps at the ‘top’ part of the pathway translating caloric restriction into longevity. The eat-2 gene encodes a nicotinic acetylcholine receptor subunit which is involved in the innervation of musculature required for eating. Mutants for this gene mimic the dietary restriction phenotype of increased longevity because of mechanical difficulties in eating. This reduced ageing phenotype is absent, however, in the presence of a second mutation in wwp-1 , which breaks the link between dietary restriction, altered metabolism and life extension. The wwp-1 and ubc-18 genes encode interacting E3 and E2 subunits, respectively, of a ubiquitin ligase complex that targets other proteins for destruction. Current research suggests that components of the TOR pathway (a sensor of amino acid nutrition) and PHA-4 protein (FOXA, a transcription factor that overlaps functionality with daf-16/FOXO) may be such targets, ultimately leading to the activation of the life-prolonging metabolic state21 . TOR signalling has received considerable interest recently because a large-scale study of dietary supplements affecting ageing in mice showed that a TOR inhibitor, rapamycin, significantly extended life span22 even when administered to aged mice. Rapamycin, already used as a cancer treatment, has immunosuppressant activity meaning that it is unlikely to be used as the first anti-ageing therapy.
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However, direct suppression of the pathways targeted by TOR (translation of mRNAs into protein and the breakdown and recycling of cellular components through the process of autophagy) might provide more specific and less harmful therapeutic options. Two principal conclusions can be made by the reader of longevity research literature. Firstly, the various pathways described above exhibit significant cross-talk at several levels. This cooperation is required to ensure detection and integration of all relevant nutritional/environmental signals and to coordinate responses across metabolic, cell cycle and genomic repair systems. Secondly, this is perhaps the clearest example of gene–environment interaction. It will be interesting to see how quickly this research moves from ‘bench to bedside’, either in the form of proactive and preventative health education policies or in the search for drug therapies mimicking the beneficial effects of dietary restriction. Finally, we may speculate on the efficiencies of evolution such that the biological processes used by unicellular organisms to withstand primordial boom-and-bust conditions have been molecularly conserved but now reworked as homeostatic mechanisms impacting on cellular proliferation, fecundity and, ultimately, life span.
REFERENCES 1. Bostock CV, Soiza RL, Whalley LJ. Genetic determinants of ageing processes and diseases in later life. Maturitas 2009; 62: 225–9. 2. Herskind AM, McGue M, Iachine IA, Holm N, Sorensen TI, Harvald B et al. Untangling genetic influences on smoking, body mass index and longevity: a multivariate study of 2464 Danish twins followed for 28 years. Hum Genet 1996; 98: 467–75. 3. McGue M, Vaupel JW, Holm N, Harvald B. Longevity is moderately heritable in a sample of Danish twins born 1870–1880. J Gerontol 1993; 48: B237–44. 4. Olshansky SJ. From Michelangelo to Darwin: the evolution of human longevity. Isr Med Assoc J 2003; 5: 316–18. 5. Richards MP. A brief review of the archaeological evidence for Palaeolithic and Neolithic subsistence. Eur J Clin Nutr 2002; 56: 16. 6. Garinis GA, van der Horst GT, Vijg J, Hoeijmakers JH. DNA damage and ageing: new-age ideas for an age-old problem. Nat Cell Biol 2008; 10: 1241–7. 7. Hasty P, Vijg J. Accelerating aging by mouse reverse genetics: a rational approach to understanding longevity. Aging Cell 2004; 3: 55–65. 8. Hayflick L. The limited in vitro lifetime of human diploid cell strains. Exp Cell Res 1965; 37: 614–36.
9. de Magalhaes JP, Faragher RG. Cell divisions and mammalian aging: integrative biology insights from genes that regulate longevity. Bioessays 2008; 30: 567–78. 10. McCarroll SA, Murphy CT, Zou S, Pletcher SD, Chin CS, Jan YN et al. Comparing genomic expression patterns across species identifies shared transcriptional profile in aging. Nat Genet 2004; 36: 197–204. 11. Murphy CT, McCarroll SA, Bargmann CI, Fraser A, Kamath RS, Ahringer J et al. Genes that act downstream of DAF-16 to influence the life span of Caenorhabditis elegans. Nature 2003; 424: 277–83. 12. Linnane AW, Marzuki S, Ozawa T, Tanaka M. Mitochondrial DNA mutations as an important contributor to ageing and degenerative diseases. Lancet 1989; 1: 642–5. 13. Taylor RW, Barron MJ, Borthwick GM, Gospel A, Chinnery PF, Samuels DC et al. Mitochondrial DNA mutations in human colonic crypt stem cells. J Clin Invest 2003; 112: 1351–60. 14. Reeve AK, Krishnan KJ, Turnbull D. Mitochondrial DNA mutations in disease, aging, and neurodegeneration. Ann N Y Acad Sci 2008; 1147: 21–9. 15. Bender A, Krishnan KJ, Morris CM, Taylor GA, Reeve AK, Perry RH et al. High levels of mitochondrial DNA deletions in substantia nigra neurons in aging and Parkinson disease. Nat Genet 2006; 38: 515–7. 16. Kraytsberg Y, Kudryavtseva E, McKee AC, Geula C, Kowall NW, Khrapko K. Mitochondrial DNA deletions are abundant and cause functional impairment in aged human substantia nigra neurons. Nat Genet 2006; 38: 518–20. 17. Kujoth GC, Hiona A, Pugh TD, Someya S, Panzer K, Wohlgemuth SE et al. Mitochondrial DNA mutations, oxidative stress, and apoptosis in mammalian aging. Science 2005; 309: 481–4. 18. Trifunovic A, Wredenberg A, Falkenberg M, Spelbrink JN, Rovio AT, Bruder CE et al. Premature ageing in mice expressing defective mitochondrial DNA polymerase. Nature 2004; 429: 417–23. 19. McCay CM, Crowell MF, Maynard LA. The effect of retarded growth upon the length of life span and upon the ultimate body size. Nutrition 1989; 5: 155–71; discussion 72. 20. Mair W, Dillin A. Aging and survival: the genetics of life span extension by dietary restriction. Annu Rev Biochem 2008; 77: 727–54. 21. Carrano AC, Liu Z, Dillin A, Hunter T. A conserved ubiquitination pathway determines longevity in response to diet restriction. Nature 2009; 460: 396–9. 22. Harrison DE, Strong R, Sharp ZD, Nelson JF, Astle CM, Flurkey K et al. Rapamycin fed late in life extends life span in genetically heterogeneous mice. Nature 2009; 460: 392–5.
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The Clinical Pharmacology of Ageing Brian Clarke and S. H. D. Jackson Department of Clinical Gerontology, Kings College Hospital, London, UK
INTRODUCTION
Absorption
The proportion of the world’s population over the age of 60 years doubled in the last century and will increase two- to threefold in the first century of this millennium1 . This population has a higher prevalence of chronic illnesses including cardiovascular diseases, cancers, osteoporosis, diabetes, Parkinson’s disease, dementia and many other conditions. An increasing body of research is adding further prescribing indications for diseases that occur in the elderly population. This, along with the increasing size of the population, means that the numbers of prescriptions for elderly patients are increasing. Depending on the age group between 60% and 80% of elderly people are taking medication and between 20% and 30% of these patients are taking at least three drugs2 . It is also estimated that although those over 75 years account for 14% of the population, they receive 33% of medication prescribed3 . An appreciation of the physiology of the ageing process and how it affects an individual’s response to, and handling of, drugs (and drug combinations) is essential to ensure safe prescribing for this vulnerable population4 . The ageing process can be described as the consequences of the sum of local effects at the cellular and molecular level. A feature of cellular ageing is the disruption of regulatory processes between cells and organs with consequent failure to maintain homeostasis. There is also time-related loss of functional units (the smallest structures still capable of performing the specific physiological activity characteristic to the organ involved) such as nephrons and neurons5 . These age-related physiological changes affect all organ systems in the body, they significantly affect how the ageing body handles and responds to pharmacological agents and hence need to be considered when prescribing. Chronic illness in older age and related organ dysfunction can compound these ageing-associated changes. In this chapter we describe the age-associated changes in physiology and consequent changes in pharmacokinetics and pharmacodynamics and their implications for prescribing in elderly patients.
Following administration, a number of factors affect a drug’s entry into the circulation. These include properties such as particle size, molecular weight, charge, solubility and pKa (the pH at which 50% remains in an un-ionized, lipid-soluble state). Most drugs are weak acids or bases and are present in solution as both ionized and nonionized species. Non-ionized drugs are lipid soluble and diffuse easily across the cell membrane. Following liberation some absorption may take place in the stomach, depending on the pKa of the drug and the pH of the stomach. Gastric acid secretion decreases with normal ageing, confounded by the widespread use of proton pump inhibitors and, to a lesser extent, H2 receptor antagonists, as well as eradication of Helicobacter pylori 5 . Drugs requiring an acidic environment to become ionized will be affected most (e.g. iron compounds). However, for most drugs the large surface area of the small bowel makes it the main site of drug absorption. With ageing, although many drugs show no change in absorption, there is slightly reduced small bowel absorption of some substances (including iron, calcium and sugar). There is slower colonic transit time with age, and an associated decrease in peristalsis, largely due a loss of neurons involved in control of the gastrointestinal tract1 . Passive intestinal permeability is probably unchanged in old age for most substances. However, active transport of other agents such as vitamin B12 is impaired. The effects of these age-related changes would influence primarily those drugs with low permeability and low solubility, e.g. cephalexin. Agents such as benzodiazepines and lithium are readily absorbed. Some agents such as neuroleptics can be esterified with long-chain fatty acids to yield depot formulations that are only slowly absorbed from the site of peripheral injection, e.g. flupentixol where the elimination half-life (t1/2 z) can be prolonged from 6 hours to 36 hours by use of an intramuscular depot preparation.
PHARMACOKINETICS AND THE AGEING PROCESS
The volume of distribution (V ), also known as apparent volume of distribution, is a pharmacological term used to quantify the distribution of a medication between plasma and the rest of the body after oral or parenteral dosing. It is defined as the volume in which the amount of drug would need to be uniformly distributed to produce a given plasma concentration. Put another way it refers to the fluid volume that would be required to contain all of the drug in the body at the same concentration as that in the blood or plasma. A drug
Pharmacokinetics is the description of how the body handles drugs after administration. It incorporates the liberation, absorption, distribution, metabolism and excretion of drugs and their metabolites. These processes may be affected by the physiological changes associated with ageing resulting in changes in the pharmacokinetics of drugs.
Distribution
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with a high V (e.g. morphine −300 litres) implies extensive distribution outside the blood or plasma to other tissues such as fat or muscle. The V is dependent on lipophilicity and the ability of the drug to bind to plasma proteins such as albumin (acidic drugs) and α1-acid glycoprotein (basic drugs) thus holding drug in the blood compartment and reducing V 6,7 . An initial phase of distribution reflects cardiac output and regional blood flow, to well-perfused organs (heart, liver, kidney and brain). A second phase, involving a larger fraction of the body mass, to muscle, skin, viscera and fat can take several minutes to hours to reach steady state. Drugs accumulating in a given tissue, such as fat, may serve as a reservoir that prolongs drug action in that same tissue or at a distant site7 . With ageing there is a decrease in lean body weight, muscle mass and body water and an increase in body fat per kg of body weight. As a result, lipid-soluble drugs such as benzodiazepines, morphine, neuroleptics and amitriptyline have an increased V due to the higher proportion of body fat. With ageing the higher V for such lipidsoluble drugs, (along with reduced clearance) will result in prolonged elimination half-life and hence drug effects. For water-soluble drugs, V will fall hence higher concentrations will be reached after initial administration. Loading doses of water-soluble drugs should, therefore, be reduced in elderly patients unless the drug also binds to muscle such as digoxin when the muscle mass would be a relevant consideration.
Protein Binding Many drugs are protein bound to a varying degree. Bound drugs are inactive. An unbound drug is free to mediate its effect. The binding is usually reversible. Most acidic drugs (diazepam, phenytoin, warfarin) bind to albumin. Basic drugs such as lidocaine and tricyclic antidepressants bind to α1-acid glycoprotein. With healthy ageing there is no substantial change in plasma proteins, however, intercurrent illness can result in a drop in albumin and an increase in α1-acid glycoprotein (an acute phase protein)5 . Chronic disease tends to accelerate the age-related decline in serum albumin. This can produce clinically significant increases in the free fraction of very heavily protein-bound drugs such as ibuprofen (99.5% bound)5 . Other highly protein-bound drugs include benzodiazepines (>90%) and many antipsychotics (>90%). Lithium, however, is not protein bound and is excreted unchanged rather than being metabolized.
Clearance – Hepatic Hepatic metabolism of drugs is dependent on the ability of the liver to extract drugs from the blood passing through the organ. Lipophilic drugs are metabolized into more hydrophilic compounds to facilitate elimination, particularly through the urine. However, in some cases metabolites are biologically active or even toxic. Thus risperidone is metabolized to an active metabolite (9-OH risperidone) which has a t1/2 z of 22 hours versus the parent drug t1/2 z of 4 hours. Similarly, diazepam is metabolized to an active metabolite (desmethyl diazepam) and amitriptyline is metabolized to nortriptyline. Both active metabolites have a longer t1/2 z than the respective parent drugs. In the liver, phase I metabolism introduces a functional group onto the parent compound, generally resulting in loss of pharmacological activity. Phase I reactions are located primarily on the endoplasmic reticulum and are performed largely through the cytochrome P450 system of enzymes. This family of enzymes
oxidize, hydroxylate or hydrolyse the drug substrate6,7 . Several studies have shown an age-related decline in the clearance of drugs by phase I metabolism, probably reflecting a reduced hepatic mass (and, for high clearance drugs, blood flow), as enzyme activity is preserved5 . Induction or increased synthesis of the cytochrome P450 enzymes induced by drugs, such as phenytoin, isoniazid, glucocorticoids and alcohol, may decrease the bioavailability of parent drug compounds. Inhibition of drug biotransformation enzymes, commonly by depletion of necessary co-factors, results in elevated levels of parent drugs. This can lead to increased pharmacological effects and an increased incidence of drug-induced toxicity. Inhibition of different isoforms of cytochrome P450 enzymes can be seen with erythromycin and ketoconazole (CYP450 3A4); SSRIs (CYP450 2D6). For two of these enzymes, CYP4502D6 and CYP4502C19, genetic polymorphisms exist that lead to poorly functioning enzymes causing individuals to be poor metabolizers. Thus when prescribing drugs metabolized by these enzymes where the therapeutic window is narrow, prescribing should be on the basis the patient is a poor metabolizer. For example when prescribing haloperidol starting doses should be those appropriate to poor CYP2D6 metabolizers. Many pharmacokinetic drug interactions occur at the level of hepatic metabolism. For example the inhibition of clozapine and chlorpromazine metabolism by cimetidine. Phase II reactions are conjugations. They are performed in the cytosolic compartment. Glucuronidation is the most important of the conjugation reactions. The increased water solubility of the glucuronide conjugates promotes their elimination in the urine or bile. Examples of drugs metabolized this way are benzodiazepines and morphine. The two main metabolites of morphine are morphine3-glucuronide and the active metabolite morphine-6-glucuronide. Although they are formed in the liver they are excreted renally and hence accumulate in chronic kidney disease. Much less effort has been directed at the investigation of the effects of ageing on the conjugative mechanisms. In general, however, studies have not reported a major effect of ageing on the pathways of conjugation.
Clearance – Renal Excretion of drugs and metabolites in the urine involves three processes: glomerular filtration; active tubular secretion; and passive tubular reabsorption. With ageing, renal mass decreases, as does glomerular filtration rate (GFR). There is also a reduced ability to concentrate urine and a reduced thirst during water deprivation. GFR decreases at an average rate of 1 ml/min/year after middle age, and is often considered the most important pharmacokinetic change in older age. A normal GFR in a young adult is 120 ml/min depending on body size. Reduction in GFR with age affects the clearance of many drugs such as water-soluble antibiotics, diuretics and lithium and some non-steroidal anti-inflammatory drugs. Declining renal function cannot be quantified by measuring serum creatinine alone as creatinine production is a reflection of muscle mass, which declines with age. Clinically significant reduced renal function may be present with a serum creatinine still within the normal range. GFR can be calculated using several equations. The Cockroft–Gault (CG) equation uses age, weight, gender and serum creatinine8 : GFR(ml/min) (140 − age)(years) × weight(kg) × (0.85 if female) = 1.23 × Creatinine (µmol/L)
NORMAL AND ABNORMAL AGEING The Renal National Service Framework recommends that all laboratories report a formula-based estimation of GFR when serum creatinine is requested in adults8 . The Modification of Diet in Renal Disease (MDRD) study equation (based on serum creatinine, age, gender and ethnic group) is widely used. The MDRD formula has the advantage of not requiring a weight, and can therefore be issued by the laboratory at the same time as a creatinine result is reported, however, it takes no account of muscle mass other than via age. Cockroft and Gault estimates tend to be lower than MDRD estimates. The adjustment of drug dosing in becomes particularly relevant where drugs are substantially or entirely excreted by the kidney. Routine pre-prescribing estimation of GFR is an essential adjunct to good prescribing in this vulnerable group. Given that the MDRD estimated GFR is now routinely provided this is the method of choice. Where there is a narrow therapeutic index, significant toxicity can occur if doses are not adjusted downwards to account for renal impairment and subsequent reduced excretion. Examples include lithium, aminoglycosides and digoxin. Lithium toxicity is manifest as neuromuscular excitability, coarse tremors, fasicular twitching, motor agitation, delirium, nausea and even seizures if severely toxic. It is the most dialysable toxin known due to its low molecular weight. Indications to dialyse include high lithium concentrations (>4 mEq/L), or a concentration >2.5 mEq/L in a markedly symptomatic patient. The presence of causes of chronic kidney disease such as hypertension and diabetes will potentiate the age-associated decline in renal function. It is especially important to review regularly drug therapy in frail older patients who may have, along with other known cardiovascular morbidities, undetected significant renal dysfunction.
Elimination Half-Life The elimination half-life (t1/2 z) is the time it takes for the plasma concentration to be reduced by 50% during the elimination phase. This is distinct from the absorption half-life (t1/2abs ) or distribution half-life (t1/2 1 ). It is a function of both volume of distribution and clearance, where clearance is the nominal volume of blood that is cleared of drug per unit time: t1/2 z = V /Cl where t1/2 z = elimination half-life; V = volume of distribution; Cl = clearance The t1/2 z provides a good indication of the time required to achieve steady state after a drug is started, and also an estimate of the time required to remove a drug from the body, and of appropriate dosing intervals. It takes approximately five half-lives to reach steady state during chronic dosing and a similar time to remove the drug when dosing is stopped. Thus for amiodarone with a t1/2 z in excess of two months in elderly patients, it would take at least 10 months to reach steady state or to remove the drug from the body. For lipidsoluble drugs, the elimination half-life increases with age, due to both reduced clearance and increased V 6,7 . For water-soluble drugs such as lithium the reduced volume of distribution partially offsets the effect of reduced clearance on t1/2 z. Renal tubular interactions are a common cause of pharmacokinetic drug interactions. For example renal tubular reabsorption of lithium is increased by thiazide and loop diuretics. This leads to reduced clearance of lithium and hence rising concentrations. Thus therapeutic drug monitoring can help manage such interactions unlike pharmacodynamic interactions (see below).
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Bioavailability and First-Pass Metabolism Bioavailability is a term used to describe the fractional extent to which an unchanged drug reaches the systemic circulation from its original site of administration. This takes into account the absorption, hepatic metabolism and biliary excretion of a drug that may occur before an oral drug reaches the systemic circulation. Drugs that undergo substantial first-pass metabolism in the liver are avidly extracted from the blood during passage through the presystemic circulation (gut wall and liver), reducing their bioavailability. Ageing is associated with a reduction in first-pass metabolism, probably due to a 20–30% reduction in liver volume with age and a concomitant reduction in liver blood flow. As a result the bioavailability of drugs that undergo extensive first–pass metabolism, such as chlormethiazole, propranolol and labetalol can be significantly increased5 .
Pharmacodynamics Pharmacodynamics can be defined as the study of the biochemical and physiological effects of drugs and their mechanisms of action. This includes therapeutic effects and unwanted effects. The effect of ageing may result in increased or decreased effect of a given drug concentration, when compared to the effect of the same concentration in a younger patient. These changes in sensitivity occur independently of any changes in pharmacokinetics that may also exist. Drugs exert their effect by binding selectively to target molecules within the body, these are usually proteins, but are also other macromolecules. The main drug targets are receptors, enzymes, ion channels, transporters (carriers) and DNA. An agonist drug uses a receptor site to activate or enhance a cellular response to that specific receptor. Benzodiazepines, for example, act as agonists at GABAa receptors. A drug that binds to a receptor target but is unable to elicit a maximal tissue response, in effect demonstrating less intrinsic activity or efficacy, is termed a partial agonist. Buspirone is an example of a partial agonist at 5-HT1A receptors, providing anxioselective effects without inducing extra-pyramidal side effects. The antipsychotic aripiprazole acts as a partial agonist at dopamine D2 receptors. An antagonist binds to a target site and inhibits the action of an endogenous agonist at that site. Mirtazapine is an antagonist at presynaptic α1 -adrenergic, 5-HT2 and 5-HT3 receptors. Most antagonists are competitive, in that they bind reversibly to a site and the effect of the antagonist may be overcome by raising the concentration of the agonist, as an example, many antipsychotics competitively antagonize dopamine receptors. Other mechanisms of antagonism include irreversible competitive antagonism, whereby raising the concentration of endogenous agonists does not overcome the antagonist’s effect: selegiline, for example, irreversibly inhibits monoamine oxidase-B. Noncompetitive antagonist drugs do not block receptors, but block the signal transduction process initiated by receptor activation. Pharmacokinetic antagonism reduces free concentration of a drug by reducing its absorption or by accelerating its elimination. A chemical antagonist combines with the drug to neutralize its effect, e.g. protamine sulphate neutralizes the action of heparin6,7 . Receptor activity and expression changes with ageing and the effect of age on drug sensitivities will vary depending on the drug studied. This makes generalizations difficult. However, there is evidence of reduced β-adrenoreceptor function in advancing age, reducing the elderly patients response to propanolol (β-adrenoceptor antagonist)
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and salbutamol (β2-adrenoceptor agonist). The responsiveness of αadrenoceptors on the other hand is preserved with advancing age. The ageing cardiovascular system also has reduced aortic and large artery elasticity and compliance, leading to higher systolic blood pressure, increased impedance to left ventricular ejection, with resultant tendency towards left ventricular hypertrophy. There is also a reduction in intrinsic heart rate and a reduction in baroreceptor sensitivity. Orthostatic intolerance increases, as the response to posture change is blunted, leading to increased postural sway and propensity to falls5,9 . This can of course be exacerbated by the concomitant use of anti-hypertensives and vasodilating drugs, and by drugs that may cause this as a side effect such as the α-blocker, tamsulosin. In the brain, cholinergic function decreases with age, thermoregulation is also impaired, especially in frail individuals. There is also reduced shivering and vasoconstriction responses to hypothermia. Frail elderly patients are particularly prone to the adverse effects of neuroleptics, including delirium (anticholinergic effect), extrapyramidal symptoms (D2 blockade), arrhythmias (prolongation of QT) and postural hypotension (α1 blockade). Of significant concern to elderly patients is the increased risk of death and cerebral ischaemia or stroke among those receiving treatment for psychosis or behavioural manifestations of dementia10 . On the basis of 17 placebo-controlled trials of new neuroleptics, involving 5106 patients with dementia-related psychosis, the US FDA reported a 1.6- to 1.7-fold increase in the risk of death associated with all atypical antipsychotics11 . The relative risk of stroke or transient ischaemic attack with risperidone is reported as high as 3.3 in this group versus controls13 . It is, however, the only neuroleptic to have a marketing authorization for short-term use in the management of persistent aggression in patients with moderate to severe Alzheimer’s disease. There is increased sensitivity to the central nervous system effects of benzodiazepines, sedation being induced at much lower concentrations with advancing age. In addition these drugs are associated with an increase in postural sway and consequently falls. Table 10.1 lists some of the more common drug-specific pharmacodynamic changes that are seen with ageing along with some examples where ageing has no effect5 . Pharmacodynamic drug interactions are those where drug A changes the effect of drug B without affecting its pharmacokinetics. Examples include the potentiation of the effects of lithium by
calcium channel blockers, the lowering of seizure threshold by tricyclics and lithium reducing the effect of anticonvulsants.
ADVERSE DRUG REACTIONS Approximately 5–10% of hospital admissions are related to managing drug-toxicity effects. Adverse drug reactions (ADRs) are common in elderly patients – it has been estimated that ADRs are the fourth to sixth leading cause of death. When adverse reactions occur in elderly patients, they are more likely to be severe and are less likely to be reported or recognized1 . ADRs can be described as dose related, in that they are predictable based on the drug’s pharmacological properties. Alternatively they may be idiosyncratic and not predictable on the basis of the pharmacological properties of the drug. These are often of an unknown mechanism and more likely to be more serious than dose-related ADRs (e.g. anaphylaxis)1,13 . Recent data suggest that half of all disability or premature deaths from medication-related problems are preventable through prescribing vigilance and monitoring3 . The presence of multiple drug treatments has been identified as an important factor associated with ADRs – the more medication the greater the chance of an ADR. However, ageing can be associated with an increased risk of adverse effects due to changes in pharmacodynamics independent of pharmacokinetics and multiple drug prescriptions. Non-steroidal anti-inflammatory drug (NSAID)-induced adverse events such as gastrointestinal haemorrhage and perforation increase with age, as does NSAID antagonism of antihypertensive therapy.
POLYPHARMACY VERSUS APPROPRIATE PRESCRIBING The art of prescribing for the elderly patient is a balance between the conflicting demands of research evidence, practical considerations and patients’ wishes. Polypharmacy can be defined as the concurrent use of multiple drugs (variously defined as the use of five or more drugs). It is no longer a useful term as it fails to encompass the omission of treatments for which there are clinical indications. Appropriate prescribing has been used to describe various aspects of medicines such as formulation and packaging, but should also be used to cover overuse, underuse and misuse of treatments. This term therefore describes not only the omission of medicines not indicated but also the use those that are indicated14 . The National Service
Table 10.1 Selected pharmacodynamic changes with ageing Drug
Pharmacodynamic effect
Adenosine Diazepam Diltiazem Diphenhydramine Enalapril Furosemide Heparin Morphine Temazepam Warfarin
Heart-rate response Sedation, postural sway Acute and chronic anti-hypertensive effect Postural sway ACE inhibition Peak diuretic response Anticoagulant effect Analgesic effect, respiratory depression Postural sway Anticoagulant effect
⇔= no significant change; ⇑= increase; ⇓= decrease
Age-related change in sensitivity ⇔ ⇑ ⇑ ⇔ ⇔ ⇓ ⇔ ⇑ ⇑ ⇑
NORMAL AND ABNORMAL AGEING Table 10.2 Causes of suboptimal drug prescribing Clinical skills • Inadequate clinical assessment leading to incorrect diagnosis • Failure to obtain history of or document previous adverse drug reactions • Failure to record current medication including over-the-counter medication • Failure to monitor response to treatment • Failure to recognize potentially serious drug interactions • Failure to recognize subtle adverse drug reactions • Failure to review repeat medication • Failure to take account of altered pharmacokinetics and pharmacodynamics • Simple error Source: Modified from the Royal College of Physicians16
Table 10.3 Prescription checklist
• • • • • • • • • • • • • • •
What are the patient’s views? What is the diagnosis (or diagnoses) you are treating? What is the main aim of treatment? What are the treatment possibilities in this patient? (non-pharmacological potential?) How are your preferred drug and its metabolites (if active) cleared? Will other disease states affect your choice? Will physiological states (e.g. ageing) affect your choice? Could one drug treat more than one problem? What is the best route and dosage? When will you dose titrate? What will its duration be? What are the potential adverse effects? What potential drug interactions are relevant? Would discontinuing another drug help? What information should you discuss with the patient?
Framework for Older People highlights the need for appropriate prescribing15 . Optimizing prescribing includes developing an awareness of the causes of suboptimal prescribing (Table 10.2) and the use of a prescription checklist to aid decisions (Table 10.3). Certain drugs should be actively avoided in elderly patients including: long-acting oral hypoglycemics as they present a high risk of hypoglycemia; long-acting benzodiazepines due to an increased risk of falls and disorientation; and non-selective anticholinergics as they can impair cognition and have significant peripheral anticholinergic side effects.
CONCLUSIONS The ageing process is characterized by functional changes in all organ systems and results in reduced homeostatic capacity. These changes affect the pharmacokinetics and pharmacodynamics of many drugs commonly used in this age group. The high prevalence of
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co-morbidities and consequent high number of concomitant prescribed drugs are major factors in the development of ADRs. The reduced functional reserve associated with ageing is also responsible for an increased vulnerability to the effects of prescribed drugs and ADRs. A knowledge and appreciation of these processes, and their consequences, is necessary to ensure appropriate and safe prescribing in this age group.
REFERENCES 1. McLean AJ, Couteur DG. Aging biology and geriatric pharmacology. Pharmacol Rev 2004; 56: 163–84. 2. Jackson SHD. Clinical trials in elderly patients. In Venitz J, Sittner W (eds), Appropriate Dose Selection: How to Optimize Clinical Drug Development . New York: Springer, 101–9, 2007. 3. Jackson SHD, Donnelly T. Therapeutics. In Rai, GS, Mulley, GP (eds), Elderly Medicine: A Training Guide, 2nd edn. London: Churchill Livingstone, 2007. 4. Swift CG. The clinical pharmacology of ageing. Br J Clin Pharmacol 2003; 56: 249–53. 5. Jackson SHD, Mangoni AA. Age-related changes in pharmacokinetics and pharmacodynamics: basic principles and practical applications. Br J Clin Pharmacol 2003; 57: 6–14. 6. Brunton LL, Lazo JS, Parker KL. Goodman Gilman’s Pharmacological Basis of Therapeutics, 11th edn. London: McGraw-Hill, 2006. 7. Rang HP, Dale MM, Ritter JM, Flower R. Rang & Dales Pharmacology, 6th edn. London: Churchill Livingstone, 2007. 8. Lamb EJ, Webb MC, O’Riordan SE. Using the modification of diet in renal disease (MDRD) and Cockroft–Gault equations to estimate glomerular filtration rate (GFR) in older people. Age Ageing 2007; 36, 689–92. 9. Moore A, Mangoni AA, Lyons D, Jackson SHD. The cardiovascular system in the ageing patient. Br J Clin Pharmacol 2003; 56: 254–60. 10. Gardner DM, Baldessarini RJ, Waraich P. Modern antipsychotic drugs: a critical overview. CMAJ 2005; 172: 1703–11. 11. Rockville (MD). FDA issues public health advisory for antipsychotic drugs used for treatment of behavioral disorders in elderly patients [FDA Talk Paper] US Food and Drug Administration,. 2005. At www.fda.gov/bbs/topics/ANSWERS/2005 /ANS01350.html. 12. Summary of clinical trial data on cerebrovascular adverse events (CVAEs) in randomized clinical trials of risperidone conducted in patients with dementia. London: Medicines and Healthcare Products Regulatory Agency, 2004. 13. Routledge PA, O’Mahony MS, Woodhouse KW. Adverse drug reactions in elderly patients. Br J Clin Pharmacol 2003; 57: 121–6. 14. Jackson SHD, Mangoni AA, Batty GM. Optimization of drug prescribing. Br J Clin Pharmacol 2003; 57: 231–6. 15. UK Department of Health. National Service Framework for Older People. London: Department of Health, 2001. 16. Royal College of Physicians. Medications for Older People. London: Royal College of Physicians, 1997.
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Cognitive Gerontology Patrick Rabbitt Neurocognitive Development Unit, School of Psychology, University of Western Australia, Australia
‘Cognitive gerontology’ is the study of changes in mental abilities and behaviour in old age and so also of changes in the brain and central nervous system that cause them. It developed alongside the rapid growth in academic psychology during the 1950s, promoted by the respect, and the access to funding that investigators, who then termed themselves ‘human experimental psychologists’, had gained by work on military applications during World War II. Leading figures of that decade were James Birren in the USA and Alan Welford in the UK. Welford was trained in applied experimental psychology and in ergonomics by Sir Frederick Bartlett. His book, Ageing and Human Skill (1958), summarizes his research with gifted colleagues in the Cambridge UK Nuffield Unit1 . This was funded to discover how the contributions of older workers to the post-war economy might be optimized by appropriate training, systems and equipment. Present sensitivity to the imminent demands of ageing populations makes these key aims of current cognitive gerontology. Birren, was convinced by his work with the distinguished psychophysicist, ‘Smitty’ Stevens that the study of perceptual systems and response times must be the most direct way to use behavioural evidence to deduce changes in the central nervous system. He greatly broadened this view when he became director of the Section on Aging in the National Institutes of Health in Bethesda, MD, where his congenial personality facilitated collaborations that confronted him with medical, biological, epidemiological, demographical and social concomitants of old age. His friend Nathan Shock had begun at Baltimore the first, longest and most thorough longitudinal study of physiological, medical social and psychological changes in a large sample of older people2 . From Shock’s experience Birren learned to appreciate the separate and interacting effects of these factors in contributing to the enormous variability between individual trajectories of ageing – points missed by colleagues with backgrounds solely in ‘mainstream’ psychology who, because neurophysiological data was then unobtainable, typically borrowed from ‘mainstream cognitive psychology’ experimental paradigms originally designed to test functional models of mental abilities in young adults. The study of age changes in mental abilities potentially offered a timely challenge to the models then current in mainstream cognitive psychology which, at that time, represented unrealistic ‘steady-state’ systems that described neither individual differences nor processes of change within them. This challenge was not met until the late 1990s, when unanticipated results from brain imaging and electrophysiology began to bring into question models that had been derived solely from behavioural evidence. These new opportunities now allow us more sensibly to address some of the
basic questions for cognitive gerontology: Why do cognitive changes occur? Are they inexorable or can we delay them? What, precisely, are the changes that occur in the brain and central nervous system and how do these affect mental abilities and behaviour? When do changes first begin and how fast do they proceed? Do all individuals age at the same rate or do some age earlier and faster than others? Do all cognitive abilities change at the same or at different rates? Do individuals experience similar or different patterns of changes in their abilities? How does ageing affect our everyday cognitive competence and what can we do to mitigate its effects? Physiologists had long recognized that because changes in the brain, body and central nervous system occur at markedly different rates in different species and individuals it is not useful to index ageing only by calendar time. They tried to derive algorithms to quantify progress of ‘biological ageing’ from a variety of different markers of the progress of physiological change3 . These algorithms are interesting in actuarial and epidemiological contexts, but have proved less fruitful than study of associations between changes in specific biological subsystems, such as are involved in vision, hearing, touch and motor control and concomitant changes in mental abilities. Sensory changes evidently affect cognitive abilities because losses of visual acuity contrast sensitivity and colour vision4 , hearing, especially in higher frequencies, tactile sensitivity, smell and taste all degrade the information that we need to perceive and interpret objects and events5 and losses of fine motor control impair our ability to respond rapidly and appropriately to our environments6 . However in addition to these direct effects of information degradation, sensory changes also have other ‘knock-on’ entrained effects because the additional effort necessary to resolve degraded sense data draws on the limited pool of information-processing resources necessary to interpret and remember what we have seen or heard7,8 . Because the time courses of sensory changes correlate robustly with those of declines in mental abilities such as intelligence, decision speed and memory, amounts of sensory losses are very effective biological markers for the extents of cognitive changes9,10 . A logical problem in interpreting such associations between changes is key to many issues in ageing studies: because all physiological, neurophysiological and cognitive changes occur over the same periods of time between their progress are inevitable but may be as functionally uninformative as between independent clocks running at different rates. Imaging of brains in vivo now resolves this issue, showing that most of the shared variance between sensory and
Principles and Practice of Geriatric Psychiatry, 3rd edn. Edited by Mohammed T. Abou-Saleh, Cornelius Katona and Anand Kumar 2011 John Wiley & Sons, Ltd
NORMAL AND ABNORMAL AGEING cognitive changes is accounted for by concomitant gross changes in brain volume and blood flow11 and prevalence of white matter lesions12 . A further question is what are the basic functional causes of these interdependent changes in general physiology and neurophysiology? Whether, for example, they are the burden of damage from pathologies and accidents that accumulates throughout the lifespan or whether some other processes, distinct from the effects of the sum of all pathologies and acquired physiological damage, that acts on all biological systems, though possibly at different rates, that is possibly genetically programmed, and so can be loosely described as ‘biological ageing’. Like most apparent dichotomies in the ‘nature/nurture’ debate, this is misleading because both endogenous and exogenous factors operate jointly and strongly interact. There is good evidence for a ‘medical model’ of ageing based on the premise that, even after differences in their calendar ages have been taken into account, the pathologies and ‘negative biological life events’ that individuals have experienced account for a large proportion of the variance in mental abilities between them. Exceptionally healthy older men retain greater ability than those with poorer health13 . Mental changes accelerate as death approaches14 and some terminal pathologies, such as diabetes and infections, are associated with faster ‘terminal decline’ in cognitive abilities than others15 . Thus, even apart from the incidence of particular neuropathologies such as dementias and cerebrovascular accidents that directly affect brain integrity, a substantial proportion of age-related decline in mental abilities is driven by a variety of pathologies that affect cerebrovasuclar sufficiency and brain metabolism. It would be useful to have quantitative estimates of exactly how much of that proportion of variance in mental abilities between older individuals, that is associated with differences in their calendar ages, can be accounted for by experience of particular pathologies. Though exact quantitative data are not yet available it seems no longer useful to argue whether cognitive changes are brought about ‘mainly’ by inexorable processes of endogenous ‘normal ageing’ or ‘mainly’ by pathologies and accidents. New technologies such as brain imaging, transient magnetic stimulation and cortical evoked potentials will soon tell us to what extent the amounts and patterns of central nervous system changes differ between individuals, what pathologies, genetic factors or life events may produce faster changes or different patterns and precisely how brain changes affect different mental abilities. ‘Cognitive gerontology’ is now a science in transition between a legacy of models to interpret a rich archive of behavioural observations and to gain an increasingly better understanding of the relationships of changes in abilities to the ageing brain and central nervous system that reveals these models to be inadequate – as indeed their proposers knew that they would as better neurophysiological evidence accumulated. Discussion of the behavioural legacy may begin with Jim Birren’s conviction that measurements of response times are an exceptionally good tool to investigate age-related cognitive change16,17 . This idea had been reinforced by Joseph Brinley’s discovery that exact estimates of average decision times for groups of older adults can be closely estimated by multiplying those of young adults by a simple constant18 . John Cerella verified this for reported data from 108 different tasks on which older and younger groups had been compared19 . Tim Salthouse greatly extended the implications of these findings by a further discovery that age-related variance in response times can also account for most of the age-related variance in errors on tests of verbal memory in which decision times are not constrained20,21 .
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He argued from this that ‘general slowing’ of the cognitive system not only reflects, but also is the main functional driver of losses in all or most other mental abilities, so that behaviourally measured changes in performance on all, or most, cognitive tasks can be related to changes in a single, very simply measured, index of task performance. This idea became central to discussions for the next 20 years. This was a very powerful theory, but also became uncomfortable because it seemed to leave nothing further to investigate. Investigators attempted various escapes. Some argued that ‘general slowing theory’ confused levels of description because behaviourally measured performance indices, such as response times, are distinct logical entities from psychometric statistical constructs such as ‘general fluid intelligence’ or ‘information processing speed’ that are computed on the basis of shared variance between performances on different tasks, and that both these entities are distinct from ‘neurophysiological system characteristics’: the many and various properties of neurones and their mutual interactions that determine their efficiency. Others re-evaluated the implications of the simple linear scaling suggested by ‘Brinley plots’22 . Other investigators beyond discussions of simple relationships between task complexity and averages of decision times to propose sophisticated models to account differences between distributions of response times produced by older and younger adults23,24 . A third escape from the constraints on discussion imposed by ‘general slowing theory’ derived from observations that neuronal changes occur earlier and are greater in the frontal and prefrontal and temporal cortex than in other parts of the brain25 . This makes it plausible that tasks derived from diagnostic tests for frontal damage, such as inhibition of irrelevant information in perception, planning, ‘working’ memory or task alternatives, may be especially sensitive to increasing age. Considered across all published studies in which no neurophysiological information is available, have been unclear. This is probably because while it is increasingly apparent that the range and variety of patterns of brain ageing differ widely between individuals behavioural comparisons have been made on small samples often of 20 persons or fewer who have not been selected on imaging data. Nevertheless more sophisticated mathematical analyses do suggest that some differences in distributions of reaction times and errors consistent with the frontal ageing hypothesis can be found, even on relatively small and unselected samples. The frequency of elderly individuals’ complaints of memory inefficiency is second only to that of their complaints about arthritis26 . Nevertheless subjective reports of memory problems seem to be associated more with current levels of depression than with objective performance. Models for age-related declines in memory efficiency have been influenced by evidence of ‘general slowing’. Craik and Lockhart showed that because the longer people are allowed to inspect and process words the better they can subsequently recall and recognize them, consequently age impairments can, at least partly, be attributed to reduced ‘depth of processing’ caused by slowing of information processing27 . There is also support for the idea that impairment may be specific to some aspects of memory tasks rather than general to all. Craik and Byrd report that age impairs the ability to select critical information to be remembered28 . However, discussions of age-related memory losses have been less constrained by the ‘general slowing’ hypothesis because most investigators have been more concerned with the nature of our memory representations of events and information than with the speed with which these can be established and retrieved. Consequently, a large literature discusses whether old age makes it more difficult to encode and recall some kinds of information rather than others. Differences are reported between verbal and
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spatial information, for faces, for proper names, for hymn tunes, and for the sources and context of correctly recalled material. There are also ‘natural history’ experiments comparing age-differences reports of vividness, detail and accuracy of so-called ‘flashbulb memories’ of striking public or private events (e.g. see29 ). Another critical distinction is between memory for information that has been acquired, used and so rehearsed over many years and memory for more recently learned material (e.g. see30 ). Conceptually related to this distinction between memory for recall of recent and distant information, for more and less frequently rehearsed material and for more and less emotionally charged and striking information are investigations of the numbers of memories that elderly people can retrieve of events from different periods of their lives31 . Most studies find a scarcity of quantity, but not necessarily of the vividness of memories from childhood. This contrasts with a ‘reminiscence bump’ of memories relating to adolescence and young adulthood, with a marked decline in memories for the very recent past31 . One explanation is that the greater efficiency of the central nervous system in youth makes memories of earlier experiences more detailed and durable. Another is that events experienced in youth are, at least when they are experienced, novel, possibly also more exciting and are likely to have been more frequently recalled in subsequent years than the probably more often repeated, and possibly more banal, experiences of late middle age and senescence. Consistent with this idea are findings that, irrespective of the ages of individuals when they experienced them, particularly eventful historical periods such as World War II are especially numerous and vivid, and of course also more often provide material for reminiscence. This distinction between the ability to recall and to use information and skills acquired over a long lifetime and continually updated by practice and the ability to remember new information and events and to learn new lessons from them is a key issue that differentiates between the study of abilities in old age and in youth. It is best defined in the work of John Horn who distinguished between what he termed ‘fluid abilities’ that are early impaired by age and ‘crystallized’ abilities’ that show relatively little decline32 . Fluid abilities are indexed by scores on tests of general intelligence and of the ability to acquire and recall new information and ‘crystallized’ abilities are indexed by tests of acquired, and subsequently continuously practised, material such as vocabulary and social skills. Memory studies have also been influenced by the hypothesis that because ageing affects the frontal and temporal lobes of the brain earlier and more severely than other areas, so the selection of relevant from irrelevant information held in memory must be more sensitive to age than other abilities (e.g. see33 ). Also associated with the frontal and temporal lobes are the abilities, collectively termed ‘prospective memory’, to use past information to anticipate what is likely to happen next, to plan how to cope with anticipated events and to retain these plans until they can be appropriately implemented34 . A key insight has been that, in old age, the efficiency of prospective memory, as indeed other kinds of memory, depends on the availability of environmental information to support recall. Studies of cognitive ageing use two methodologies: cross-sectional comparisons between groups of different ages and longitudinal studies in which the same groups are repeatedly assessed. These can very profitably be combined by analyses including both kinds of comparisons35 (see Baltes, 1968). A pervasive difficulty for both is inadvertent selection of participants. Elderly individuals who volunteer for demanding studies are atypically able and well members of their generations and are usually also better educated, more likely to have practised intellectually demanding professions and are usually
also not socioeconomically disadvantaged. Representation of ethnic minorities is also questionable. In more arduous longitudinal studies self-selection of volunteers not only biases initial recruitment but also brings about selective attrition because less healthy and so least able participants withdraw or die leaving a progressively elite group of survivors. So, in longitudinal studies, true rates of cognitive change will be miscomputed unless the incidence of these deaths and dropouts is taken into consideration14 . Another difficulty for longitudinal studies of mental abilities is that if participants are repeatedly given the same, or similar, tests even at intervals of many years, they show significant practice effects. This also leads to potential miscomputations of trajectories of change, more particularly because older and less able individuals, and those who approach dropout or death, experience less improvement from practice than the younger, more intelligent and more healthy. Anstey, Hofer and Luszcz illustrate how some of these issues can be dealt with in an exploration of both cross-sectional and longitudinal examinations of the ways in which correlations between sensory and cognitive variables change over time9 . It is becoming questionable whether very large and prolonged longitudinal studies that collect only behavioural data on cognitive change, with additional data on health and demographics, are the most resource-effective way of learning how and why age affects mental abilities. The rapid development of non-invasive brain imaging means that we can now detect changes in the brain and central nervous system over periods measured in months rather than decades that can be related to cotemporaneous patterns of cognitive changes within individuals. Thus, even with small samples we can study variability in idiosyncratic patterns of brain changes and correspondingly patterned changes in cognition36 . Raz et al. provide excellent general discussions of how such studies can be carried out and what they can tell us37 . An explosion of studies of relationships between changes in specific brain locations and in particular aspects of cognitive performance includes age differences in the functional neuroanatomy of verbal recognition memory38 , the functional neuroanatomy of age related changes in visual attention39 , changes in entorhinal cortex and losses of memory function, age-related differences in working memory using real-time fMRI, differences in brain activity associated with age-related changes in memory function and brain changes associated with changes in motor performance. These relationships between changes in specific brain locations and in specific abilities proceed against a background of global changes affecting all parts of the brain such as increasing prevalence and distribution of white-matter lesions, losses in brain volume and declines in cerebral blood flow that all appear to be associated with declines in information processing rate11,12 . This complicates interpretation of cognitive effects of localized brain changes that may be masked or blurred by these global changes that affect all systems, but to different degrees. This may partially explain apparent contradictions between the results of the many studies using behavioural evidence alone to test the sensible hypothesis that earlier and faster ‘ageing’ of the prefrontal cortex must result in correspondingly more marked age decrements in abilities such as working memory, planning, attention and executive functions. For example most of the adapted behavioural clinical diagnostic tests for frontal damage tests used to test this hypothesis are scored in terms of the relative speed with which decisions can be made. Since we know that gross brain changes such as white-matter lesion incidence specifically impair processing speed, scores on so-called ‘frontal’ tasks must evidently reflect some complex combination of local and global effects. It is therefore unsurprising that comparisons between small groups of 30 or fewer individuals
NORMAL AND ABNORMAL AGEING for whom information on brain status is not available should only sometimes find evidence for the ‘frontal ageing’ hypothesis. With these cautions, ‘cognitive gerontology’ is now becoming an exciting science in which a rich body of behavioural data and growing sophistication in understanding brain changes is rapidly transforming our understanding of how and why our mental abilities change, why all of us do not change at the same speed or in the same ways and, hopefully, suggest what we may do about this.
REFERENCES 1. Welford AT. Ageing and Human Skill . Oxford: Oxford University Press, 1958. 2. Shock NW, Greulich RC, Andres R, Arenberg D, Costa PT, Lakatta EG, Tobin JD. Normal Human Aging. The Baltimore Longitudinal Study of Aging. NIH Publ. No 84-2450. Washington, DC: US Government Printing Office, 1984. 3. Borkan GA, Norris AH. Biological age in adulthood. Comparison of active and inactive US males. Hum Biol 1980; 52: 787–802. 4. Faubert J. Visual perception and aging. Can J Exp Psych 2000; 56: 164–75. 5. Corso J. Aging, Sensory Systems and Perception. New York: Praeger, 1981. 6. Goodpaster BH, Park SW, Harris TB, Kritchevsky SB, Nevitt M, Schwartz AV et al . The loss of skeletal muscle strength, mass, and quality in older adults: the health, aging and body composition study. J Gerontol Med Sci 2006; 61A: 1059–64. 7. Dickenson CM, Rabbitt PMA. Simulated visual impairment: effects on text comprehension and reading speed. Clin Vision Sci 1991; 6: 301–8. 8. van Boxtel MPJ, van Beijsterveldt CEM, Houx PJL, Acteunis JC, Metsemakers JFM, Jolles J. Mild hearing impairment can reduce verbal memory performance in a healthy adult population. J Clin Exp Neuropsychol 2000; 22: 147–54. 9. Anstey KJ, Hofer SM, Luszcz MA. A latent growth curve analysis of late-life sensory and cognitive function over 8 years: evidence for specific and common factors underlying change. Psychol Aging 2003; 18: 714–26. 10. Lindenberger U, Scherer H, Baltes B. The strong connection between sensory and cognitive performance in old age: not due to sensory acuity reductions operating during cognitive assessment. Psychol Aging 2001; 16: 196–205. 11. Rabbitt P, Mogape O, Scott M, Lowe C, Thacker N, Pendleton N et al . Effects of global atrophy, white matter lesions and cerebral blood flow on age-related changes in speed, memory, intelligence, vocabulary, and frontal function. Neuropsychol 2007; 21: 684–95. 12. Deary IJ, Leaper SA, Murray AD, Staff RT, Whalley LJ. Cerebral white matter abnormalities and lifetime cognitive change: a 67 year follow up of the Scottish Mental Survey 1932. Psychol Aging 2003; 18: 140–8. 13. Houx PJ, Vreeling FW, Jolles J. Rigorous health screening reduces age effects on a memory scanning task. Brain Cogn 1991; 15: 246–60. 14. Rabbitt P, Lunn M & Wong D. Understanding terminal decline in cognition and risk of death: Methodological and theoretical implications of practice and dropout effects. European Psychologist 2006; 11: 164–171.
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15. Small BL, Fratiglione L, vonStrauss E & Backman L. Terminal Decline and Cognitive Performance in Very Old Age: Does Cause of Death Matter? Psychology and Aging 2003; 18: 193–202. 16. Birren JE. The significance of age-changes in speed of perception and psychomotor skills. In Anderson JE (ed.), Psychological Aspects of Aging. Washington, DC: American Psychological Association, 1956. 17. Birren JE. Tutorial review of changes in choice response time with advancing age. In Baumeister H (ed.), Bayer Symposium No 6 . Bonn: Springer-Verlag, 1979, 232–47. 18. Brinley JE. Cognitive sets, speed and accuracy of performance in the elderly. In Welford AT, Birren JE (eds), Behavior, Aging and the Nervous System. Springfield, IL: Charles Thomas, 1965. 19. Cerella J. Information processing rates in the elderly. Psychol Bull 1985; 98(1): 67–83. 20. Salthouse TA. A Theory of Cognitive Aging. Amsterdam: Elsevier Science, 1985. 21. Salthouse TA. The processing-speed theory of adult age differences in cognition. Psychol Rev 1996; 103(3): 403–28. 22. Myerson J, Hale S, Wagstaff D, Poon L & Smith G. The information-loss model: A mathematical theory of age-related cognitive slowing. Psychological Review 1990; 97(4): 475–87. 23. Ratcliff D, Spieler D, McKoon G. Explicitly modeling the effects of aging on response time. Psychonom Bull Rev 2000; 7(1): 1–25. 24. Verhaeghen P, Cerella J. Everything we know about aging and response times: a meta-analytic integration. In Hofer SM, Alwin DF (eds), The Handbook of Cognitive Aging: Interdisciplinary Perspectives. Thousand Oaks: Sage, 2008, 134–50. 25. West RL. An application of prefrontal cortex function theory to cognitive aging. Psychol Bull 1996; 120(2): 272–92. 26. Guttman JM. The elderly at home and in retirement housing: a comparative study of health problems, functional difficulties and support service needs. In Marshall VW (ed.), Aging in Canada: Social Perspectives. Ontario: Fitzhugh & Whiteside, Don Mills, 1980, 232–59. 27. Craik FIM, Lockhart RS. Levels of processing: a framework for memory research. J Verb Learn Verb Behave 1972; 11: 671–84. 28. Craik FM, Byrd TD. Aging and cognitive deficits: the role of attentional resources. Aging Cogn Proc 1982; 191–211. 29. Cohen G, Conway MA, Maylor EA. Flashbulb memories in older adults. Psychol Aging 1994; 9(3): 454–63. 30. Charness N, Kelley CL, Bosman EA, Mottram M. Word processing training and retraining: effects of adult age, experience and interface. Psychol Aging 2001; 16(1): 110–27. 31. Fitzgerald JM, Lawrence R. Autobiographical memory across the life-span. J Gerontol B 1984; 39: 692–8. 32. Horn, J. The theory of fluid and crystallized intelligence in relation to concepts of cognitive psychology and aging in adulthood. In Craik FM, Trehub S (eds), Aging and Cognition Processes. New York: Plenum Press, 1982, 237–78. 33. Zacks RT, Hasher L. Directed ignoring: inhibitory regulation of working memory. In Dagenbach D, Carr TH (eds), Inhibitory Mechanisms in Attention, Memory, and Language. New York: Academic Press, 1994, 241–64. 34. McDaniel A, Einstein G, Stout S, Morgan R. Aging and maintaining intentions over delays: do it or lose it. Psychol Aging 2003; 18(4): 823–35.
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35. Baltes PB. Longitudinal and cross-sectional sequences in the study of age and generation effects. Human Development 1968; 11: 145–171. 36. Grady CL. Functional brain imaging and age-related changes in cognition. Biol Psychol 2000; 54(1–3): 259–81. 37. Raz N, Lindenberger U, Rodrigue KM, Kennedy HM, Head D, Williamson A et al. Regional brain changes in aging healthy adults: general trends, individual differences and modifiers. Cerebral Cortex 2005; 15: 1676–89.
38. Madden DJ, Turkington TG, Provenzale JM, Denny LL, Hawk TC, Gottlob LR, Coleman RE. Adult age differences in the functional neuroanatomy of verbal recognition memory. Hum Brain Mapping 1999; 7: 115–35. 39. Madden DJ, Spaniol J, Whiting WL, Bucur B, Provenzale JM, Cabeza R et al. Adult age differences in the functional neuroanatomy of visual attention. A combined fMRI and DTI study. Neurobiol Aging 2007; 3: 459–76.
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Chronological and Functional Ageing David Melzer and Iain Lang Peninsula Medical School, University of Exeter, UK
INTRODUCTION Ageing is a surprisingly difficult process to define or measure. In a superficial sense it is everything that happens to an individual over time but, for geriatricians and gerontologists, notions of ageing are tied to physiological deterioration and increasing vulnerability to diseases absent in the young. This notion of ageing is synonymous with ‘senescence’ and is defined1 as progressive deterioration during adult life that underlies an increasing vulnerability to challenges and a decreased chance of survival. The relationship between chronological and functional age has implications for ageing research and public policy. In this chapter we describe more meaningful ways of thinking about human ageing than through the proxy of elapsed time, or chronological ageing.
THE PLASTICITY OF AGEING Ageing is widely seen as the result of lifelong accumulation of random molecular damage2 . Damage results in declining function at many levels3 , including in mitochondrial function, DNA transcription (through unrepaired somatic DNA mutations) and in the ability of cells to divide and repair tissues. The balance between damage and repair mechanisms determines the amount of unrepaired damage, which manifests as ageing at the cellular and organism level. Secondary responses to damage can then occur, including chronic inflammation, hypothesized as a major element in human ageing4 . Ageing processes are surprisingly plastic and variable. This is evident at all levels from the molecular to the societal and global population levels. The most dramatic demonstration of the plasticity of ageing is the finding that hundreds of mutant genes (mainly knockouts) can produce radical life extensions in model organisms5 . In addition to affecting stress responses and telomeres, endocrine signalling has also emerged as particularly important in these models. In general, the impact of ‘longevity’ gene manipulation on lifespan becomes progressively smaller on moving up the evolutionary ladder6 and relevance to human ageing is speculative. In addition to genetic manipulation, caloric restriction in laboratory settings also increases lifespan when compared to unlimited feeding7,8 . In humans, obesity is a risk for mortality and functioning in older people9 but whether there are benefits in radically reducing caloric intakes below those required for maintaining a healthy weight is unclear.
The variability of ageing in humans is apparent both in single organs and in the longevity and functioning of individuals. Analyses of the Baltimore Longitudinal Study of Ageing have shown marked heterogeneity in the rates of decline in function of different organ systems: for example, mean maximum work rate and renal blood flow generally decline far faster than measures of nerve conduction10 . More surprising, individuals show great heterogeneity in patterns of impairment of individual systems, with little indication of typical patterns. In human population studies, it is usual to find people functioning at a higher level than others aged 20 or 30 years younger. One potential means of identifying an individual’s ‘true’ age is through identifying biomarkers of ageing. The concept of biomarkers of ageing is appealing because it implies biological measures can reflect the rate of ageing and that successful interventions on the ageing process may affect these markers. The American Federation for Aging Research proposed that a biomarker of ageing must11 :
• predict the rate of ageing – i.e. it should be a better predictor of lifespan than chronological age;
• monitor a basic process that underlies the ageing process, not the effects of disease;
• be testable repeatedly without harming the person; • be valid in humans and in laboratory animals. Markers showing potential include telomere length12 and p16INK4a expression13 . The search for biomarkers of ageing assumes there is an underlying biological state of ageing that can be summed up as a single number but counterarguments regard ageing as a complex, uncoordinated phenomenon that cannot be encapsulated so simply14 . Despite much research effort, most gerontologists accept that no biomarkers of ageing have yet been validated11,15 .
FUNCTIONAL HEALTH STATUS A key aspect of functional ageing or functional health status assesses functioning at the level of the whole older person. Functional health status is related to chronological age, disease and need for care, and understanding the functional aspects of ageing is an important part of geriatric medicine. In the medical model of disease, the clinician gathers symptoms and signs, makes a diagnosis and bases the therapeutic approach on this diagnosis. Complementing this
Principles and Practice of Geriatric Psychiatry, 3rd edn. Edited by Mohammed T. Abou-Saleh, Cornelius Katona and Anand Kumar 2011 John Wiley & Sons, Ltd
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disease-orientated approach, functional assessment provides an understanding of the impact and consequences of the older person’s disease or diseases, giving information on level of independence and prognosis, as well as health care, rehabilitation and social needs. Since a major impact on functional health comes from disease, a framework that represents the relationship between disease and disability is valuable in developing the concept of functional ageing. The World Health Organization (WHO) originally proposed a theoretical pathway progressing from disease to impairment to disability to handicap16 . An alternative pathway, proposed by Nagi17 and utilized by the US Institute of Medicine18 , progresses from diseases and conditions to impairment to functional limitation to disability. An effort to operationalize this latter pathway defines ‘impairment’ as dysfunction and structural abnormalities in specific body systems, ‘functional limitation’ as restriction in basic physical and mental actions such as ambulating, grasping, and stepping up, and ‘disability’ as difficulty in doing activities in daily life such as personal care, household management, job and hobbies19 . The importance of identifying external factors that needlessly cause disablement outside the individual is a major theme in the more recent WHO classification systems20 . Means of assessing and reporting functional health status include the following.
Self-Reported Functioning Physical functioning shows a downwards trend with age and is often assessed through self-report of the ability to perform specific tasks, including self-care activities such as bathing and dressing (activities of daily living), and activities necessary to maintain independence in the community, such as shopping and food preparation (instrumental activities of daily living)21 – 24 . A concern with self-reported functioning is that different individuals and groups may have different thresholds for reporting difficulty or inability to carry out activities25 .
Performance Measures Performance measures of functioning, in which the individual is asked to carry out standardized tasks, offer a way of benchmarking function and comparing over time or across populations26 . Selfreported functional status may differ from measured function for a variety of reasons, including differences in the domains measured. Assessing both allows us to combine an objective measure of poor performance with an indication of how much everyday function is affected27 . Tests of physical function are used in clinical assessments of older people28,29 and can help identify individuals with pre-clinical limitations who are at increased risk of developing disabilities30,31 . One established measure is the short physical performance battery, including measures of gait speed, chair stands and tandem balance tests: this score has been widely used in clinical settings for the assessment of mobility limitations32 . Other approaches include these measures plus muscle strength and respiratory function33 .
Frailty Frailty, generally taken to mean multisystem impairment and a high level of vulnerability, has been defined in two ways: as a phenotype; and as a score of age-related deficits or ‘frailty index’. The phenotypic approach defines frailty as a clinical syndrome in relation to five criteria: unintentional weight loss (10 lbs or more in the
preceding year); self-reported exhaustion; weakness (grip strength); slow walking speed; and low physical activity34 . Using these criteria, individuals are defined as either frail (three or more criteria present) or not frail (fewer than three criteria). The frailty index approach sums the number of age-associated deficits experienced by an individual, including symptoms, signs, diseases and disabilities35 (Rockwood 2007). The resulting score provides an indication of the likelihood that frailty is present, and the index demonstrates characteristic changes with age. Each of these operationalizations of frailty has been validated in multiple populations. Although the two approaches overlap there are substantial differences between them36 and it has been suggested each represents a different form of frailty and a different trajectory of age-related loss of function37 .
Cognitive Function Age-related functional decline has cognitive as well as physical aspects. These often occur together, and they share some risk38 as well as protective39 factors. The care burden associated with dementia, on both a societal40 and a household level41 level, is large. There are major public health concerns about the impact on health and social care services of growing numbers of older people with declining cognitive function and dementia42 . Among the challenges of dealing with this growing problem is the shortage of effective treatments for dementia, and attention has been drawn to identifying individuals with mild cognitive impairment – that is, those who are not demented but have a memory impairment beyond that expected for age and education43 . Cognitive function and dementia are covered in more details in Part IV of this book.
Factors Affecting Functional Health Status The prevalence of disability in activities of daily living (ADL) in the non-institutionalized population rises steeply with increasing age and is higher in women than men at the older ages44 – see Figure 12.1.
45 40 35 % of population
66
30 25
3+ 1−2
20 15 10 5 0
50−54
55−59
60−64 65−69 70−74 Age-group (yrs)
75−79
80+
Figure 12.1 Percentage of community-living respondents reporting one to two, and three or more disabilities in activities of daily living. Activities include dressing, walking across a room, getting in and out of bed, eating and using the toilet Source: Data from the English Longitudinal Study of Ageing (Steel et al ., 2004)
NORMAL AND ABNORMAL AGEING The prevalence of ADL disabilities in institutional settings is generally very high. It is important to keep in mind that, although chronological age is strongly related to disability prevalence, many other factors, particularly socioeconomic status, have large impacts on disability that are independent of age45,46 . Large differences in functional health status exist between groups, with those in less privileged social positions having higher rates of incidence and prevalence of disability, in both developed47 and emerging countries48 . Cognitive impairment is a major contributor to functional disability49,50 , as are depressive symptoms51,52 . A number of potentially modifiable behaviours are associated with physical function or functional decline in later life. These include obesity53 , smoking54 and low levels of physical activity55 . The onset of functional disability often occurs relatively early in life: recent studies have identified that up to one in five adults aged 50–64 experiences some problems with walking a quarter of a mile56,57 .
LONG-TERM TRENDS IN FUNCTIONAL HEALTH STATUS AND POLICY IMPLICATIONS An important issue connected to functional ageing is the relationship between length of life and time spent in a disabled state. Life expectancy increased substantially through the 20th century. One consequence of reduced early-life mortality may be that more people survive to ages where they suffer from chronic diseases, leading to increased prevalence of long-term disability and loss of independence. Increases in life expectancy which bring longer periods of life with impaired function are undesirable both for individuals and for societies and a major goal of gerontology is increasing longevity without increasing the number of years spent in the disabled or dependent state. An important concept in relation to evaluating the consequences of worldwide population ageing is ‘active life expectancy’ or ‘disabilityfree life expectancy’58 . Active life expectancy is defined as the average number of years an individual at a given age will survive and remain in the active, or non-disabled, state. Most analyses of active life expectancy define disability in relation to activities of daily living, with active life expectancy calculated using life-table techniques that consider transitions from the active, non-disabled state to a disabled state or death. The original analysis of active life expectancy considered the transitions to both death and disability as irreversible58 but recent studies have shown a substantial proportion of disabled persons returns, at least temporarily, to the non-disabled state59 .
Compression of Morbidity A related theory is ‘compression of morbidity’60 , the idea that the burden of lifetime illness may be compressed into a shorter period prior to death. Fries argued that in all species the maximum lifespan is fixed, human beings are quickly approaching this limit, and with a stable life expectancy any postponement of disease and disability would result in a compression of morbidity. He stated the compression of morbidity was inevitable and predicted a decrease in the period people could expect to spend with severe disease and disability. The relationship over time between life expectancy and active life expectancy can be used to assess the occurrence of a compression of morbidity. Three possible scenarios for population morbidity in women are illustrated schematically in Figure 12.2. The total length of the bars in this figure represents life expectancy for Non-Hispanic black U.S. females projected by the Census Bureau for 2050. The
67 Disability-free life expectancy
Life expectancy 77.1 years
2010
Scenario 1: Stable population morbidity 84.3 years
2050 Scenario 2: Compression of morbidity
84.3 years
2050 Scenario 2: Expansion of morbidity
84.3 years
2050 Years of life free of disability
Years disabled
Figure 12.2 Scenarios for change in average burden of population disability level: compression of morbidity and alternatives
length of the unshaded segments of the bars represents active or disability-free life expectancy, and the shaded areas of the bars represent the average number of years in the disabled state. In scenario 1, the onset of disability has been postponed the same number of years as life expectancy has increased, and the number of years spent in the disabled state is unchanged from 2010. In scenario 2, there has been a compression of morbidity. Finally, in scenario 3, although disability-free life expectancy in 2050 has increased compared with 2010, it has not kept pace with increases in life expectancy and there is an expansion of population morbidity. Active life expectancy is not always easy to assess and debates persist about whether compression of morbidity is taking place. However, trends in disability can be estimated in other ways. It is possible to estimate disability prevalence, which is not equivalent to disabled life expectancy but reflects a cross-sectional picture of the proportion of the population that is disabled. Much attention has been focused on examining longitudinal trends in disability by analysing annual estimates of disability prevalence. In the US, it appeared that in the 1970s the prevalence of age-related disability was rising but in the 1980s rates declined61 – 63 and this trend seems to have continued. A number of studies have reported ongoing year-on-year improvements in the health of the older population61,64 – 66 and reports from other countries, including New Zealand67 and England68 suggest similar patterns of decline in age-related disability may also be occurring there. Possible causes of these declines in disability prevalence include environmental changes making daily tasks easier19 , more intensive use of assistive devices69 and other social changes, including attitudes to being active in old age. In addition, the proportion of older people who have little education (a potent risk factor for disability) has declined63,70 . There is evidence of declining prevalence of some medical conditions in old age, especially cardiovascular disease, and health risk avoidance and improved diagnostic and therapeutic techniques will also have contributed71 . The future burden of morbidity and disability in the older population is of great concern to those involved in planning, financing and delivering health care and social services. If current rates of disabling diseases such as Alzheimer’s disease and hip fracture remain unchanged, the numbers of older people with these diseases will increase substantially during this century72 . Understanding the factors that affect functional ageing is critical to reducing the burden of disability and compressing morbidity. Effective interventions are needed to prevent the onset and mitigate the consequences of diseases and conditions that lead to much disability in later life.
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23. Guralnik JM (ed.). Assessing Physical Function in Older Populations. New York: Oxford University Press, 1991. 24. Lawton MP, Brody EM. Assessment of older people: selfmaintaining and instrumental activities of daily living. Gerontologist 1969; 9: 179–86. 25. Melzer D, Lan TY, Tom BDM, Deeg DJH, Guralnik JM. Variation in thresholds for reporting mobility disability between national population subgroups and studies. J Gerontol A Biol Sci Med Sci 2004; 59: 1295. 26. Guralnik JM, Branch LG, Cummings SR, Curb JD. Physical performance measures in ageing research. J Gerontol 1989; 44: M141–6. 27. Reuben DB, Seeman TE, Keeler E, Hayes RP, Bowman L, Sewall A et al . Refining the categorization of physical functional status: the added value of combining self-reported and performance-based measures. J Gerontol A Biol Sci Med Sci 2004; 59: 1056–61. 28. Guralnik JM, Ferrucci L. Assessing the building blocks of function: utilizing measures of functional limitation. Am J Prev Med 2003; 25: 112–21. 29. Studenski S, Perera S, Wallace D, Chandler JM, Duncan PW, Rooney E et al . Physical performance measures in the clinical setting. J Am Geriatr Soc 2003; 51: 314–22. 30. Cesari M, Kritchevsky SB, Penninx BW, Nicklas BJ, Simonsick EM, Newman AB et al . Prognostic value of usual gait speed in well-functioning older people – results from the Health, Ageing and Body Composition Study. J Am Geriatr Soc 2005; 53: 1675–80. 31. Melzer D, Gardener E, Lang IA, Williams B, Guralnik JM. Measured physical performance. In Banks J, Lessof C, Nazroo J (eds), Retirement, Health and Relationships of the Older Population in England: The 2004 English Longitudinal Study Of Ageing (Wave 2). London: Institute for Fiscal Studies, 2006, 165–78. 32. Studenski S, Perera S, Wallace D, Chandler JM, Duncan PW, Rooney E et al . Physical performance measures in the clinical setting. J Am Geriat Soc 2003; 51: 314–22. 33. Lan TY, Melzer D, Tom BD, Guralnik JM. Performance tests and disability: developing an objective index of mobility-related limitation in older populations. J Gerontol A Biol Sci Med Sci 2002; 57: M294. 34. Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J et al . Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci 2001; 56: M146–56. 35. Rockwood K, Mitnitski A. Frailty in relation to the accumulation of deficits. J Gerontol A Biol Sci Med Sci 2007; 62: 722–7. 36. Hubbard RE, O’Mahony MS, Woodhouse KW. Characterising frailty in the clinical setting – a comparison of different approaches. Age Ageing 2009; 38: 115–19. 37. Cigolle CT, Ofstedal MB, Tian Z, Blaum CS. Comparing models of frailty: the Health and Retirement Study. J Am Geriatr Soc 2009; 57: 830–9. 38. Llewellyn DJ, Lang IA, Xie J, Huppert FA, Melzer D, Langa KM. Framingham stroke risk profile and poor cognitive function: a population-based study. BMC Neurol 2008; 8: 12. 39. Williamson JD, Espeland M, Kritchevsky SB, Newman AB, King AC, Pahor M et al . Changes in cognitive function in a randomized trial of physical activity: results of the lifestyle interventions and independence for elders pilot study. J Gerontol A Biol Sci Med Sci 2009; 64: 688–94. 40. Schneider EL, Guralnik JM. The ageing of America. Impact on health care costs. JAMA 1990; 263: 2335–40.
NORMAL AND ABNORMAL AGEING 41. Dunkin JJ, Anderson-Hanley C. Dementia caregiver burden: a review of the literature and guidelines for assessment and intervention. Neurology 1998; 51: S53–60; discussion S65–7. 42. Ferri CP, Prince M, Brayne C, Brodaty H, Fratiglioni L, Ganguli M et al . Global prevalence of dementia: a Delphi consensus study. Lancet 2005; 366: 2112–7. 43. Petersen RC, Smith GE, Waring SC, Ivnik RJ, Tangalos EG, Kokmen E. Mild cognitive impairment: clinical characterization and outcome. Arch Neurol 1999; 56: 303–8. 44. Steel N, Huppert FA, McWilliams B, Melzer D, Marmot M, Banks J et al . Physical and cognitive function. Health, Wealth and Lifestyles of the Older Population in England: The 2002 English Longitudinal Study of Ageing. London: Insitute of Fiscal Studies, 2004. 45. Stuck AE, Walthert JM, Nikolaus T, Bula CJ, Hohmann C, Beck JC. Risk factors for functional status decline in community-living elderly people: a systematic literature review. Soc Sci Med 1999; 48: 445–69. 46. Lang IA, Llewellyn DJ, Langa KM, Wallace RB, Huppert FA, Melzer D. Neighborhood deprivation, individual socioeconomic status, and cognitive function in older people: analyses from the English Longitudinal Study of Ageing. J Am Geriatr Soc 2008; 56: 191–8. 47. Melzer D, Izmirlian G, Leveille SG, Guralnik JM. Educational differences in the prevalence of mobility disability in old age: the dynamics of incidence, mortality, and recovery. J Gerontol B Psychol Sci Soc Sci 2001; 56: S294. 48. Parahyba MI, Stevens K, Henley W, Lang IA, Melzer D. Reductions in disability prevalence among the highest income groups of older Brazilians. Am J Public Health 2009; 99: 81–6. 49. Melzer D, McWilliams B, Brayne C, Johnson T, Bond J. Profile of disability in elderly people: estimates from a longitudinal population study. BMJ 1999; 318: 1108. 50. McGuire LC, Ford ES, Ajani UA. Cognitive functioning as a predictor of functional disability in later life. Am J Geriatric Psych 2006; 14: 36–42. 51. Ormel J, Rijsdijk FV, Sullivan M, Van Sonderen E, Kempen GI. Temporal and reciprocal relationship between IADL/ADL disability and depressive symptoms in late life. J Gerontol B Psychol Sci Soc Sci 2002; 57: P338–47. 52. Berkman LF, Berkman CS, Kasl S, Freeman DH, Leo L, Ostfeld AM et al. Depressive symptoms in relation to physical health and functioning in the elderly. Am J Epidemiol 1986; 124: 372–88. 53. Angleman SB, Harris TB, Melzer D. The role of waist circumference in predicting disability in periretirement age adults. Int J Obes (Lond) 2006; 30: 364. 54. Vita AJ, Terry RB, Hubert HB, Fries JF. Ageing, health risks, and cumulative disability. N Engl J Med 1998; 338: 1035–41. 55. Lang IA, Guralnik JM, Melzer D. Physical activity in middleaged adults reduces risks of functional impairment independent of its effect on weight. J Am Geriatr Soc 2007; 55: 1836–41. 56. Gardener EA, Huppert FA, Guralnik JM, Melzer D. Middleaged and mobility-limited: prevalence of disability and symptom attributions in a national survey. J Gen Intern Med 2006; 21: 1091.
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57. Mottram S, Peat G, Thomas E, Wilkie R, Croft P. Patterns of pain and mobility limitation in older people: cross-sectional findings from a population survey of 18,497 adults aged 50 years and over. Qual Life Res 2008; 17: 529–39. 58. Katz S, Branch LG, Branson MH, Papsidero JA, Beck JC, Greer DS. Active life expectancy. N Engl J Med 1983; 309: 1218–24. 59. Hardy SE, Dubin JA, Holford TR, Gill TM. Transitions between states of disability and independence among older persons. Am J Epidemiol 2005; 161: 575–84. 60. Fries JF. Aging, natural death, and the compression of morbidity. N Engl J Med 1980; 303: 130–5. 61. Manton KG, Stallard E, Corder LS. The dynamics of dimensions of age-related disability 1982 to 1994 in the U.S. elderly population. J Gerontol A Biol Sci Med Sci 1998; 53: B59–70. 62. Crimmins EM, Saito Y, Reynolds SL. Further evidence on recent trends in the prevalence and incidence of disability among older Americans from two sources: the LSOA and the NHIS. J Gerontol B Psychol Sci Soc Sci 1997; 52: S59–71. 63. Freedman VA, Martin LG. Understanding trends in functional limitations among older Americans. Am J Public Health 1998; 88: 1457–62. 64. Freedman VA, Crimmins E, Schoeni RF, Spillman BC, Aykan H, Kramarow, E et al . Resolving inconsistencies in trends in old-age disability: report from a technical working group. Demography 2004; 41: 417–41. 65. Manton KG, Corder L, Stallard E. Chronic disability trends in elderly United States populations: 1982–1994. Proc Natl Acad Sci USA 1997; 94: 2593–8. 66. Kramarow E, Lubitz J, Lentzner H, Gorina Y. Trends in the health of older Americans, 1970–2005. Health Aff (Millwood) 2007; 26: 1417–25. 67. Graham P, Blakely T, Davis P, Sporle A, Pearce N. Compression, expansion, or dynamic equilibrium? The evolution of health expectancy in New Zealand. J Epidemiol Community Health 2004; 8: 659–66. 68. Jagger C, Matthews R, Matthews F, Robinson T, Robine JM, Brayne C. The burden of diseases on disability-free life expectancy in later life. J Gerontol A Biol Sci Med Sci 2007; 62: 408–14. 69. Manton KG, Corder L, Stallard E. Changes in the use of personal assistance and special equipment from 1982 to 1989: results from the 1982 and 1989 NLTCS. Gerontologist 1993; 33: 168–76. 70. Singer BH, Manton KG. The effects of health changes on projections of health service needs for the elderly population of the United States. Proc Natl Acad Sci USA 1998; 95: 15618–22. 71. Schoeni RF, Freedman VA Martin LG. Why is late-life disability declining? Milbank Q 2008; 86: 47–89. 72. Jagger C, Matthews R, Lindesay J, Robinson T, Croft P, Brayne C. The effect of dementia trends and treatments on longevity and disability: a simulation model based on the MRC Cognitive Function and Ageing Study (MRC CFAS). Age Ageing 2009; 38: 319–25; discussion 251.
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Successful Ageing Ann Bowling Department of Primary Care and Population Health, University College London, UK
BACKGROUND
SOCIAL FUNCTIONING
Population ageing and increases in life expectancy in the developed world have led to international interest in how to age ‘successfully’. But there is no interdisciplinary agreement on what successful ageing is. The literature reveals that conceptual definitions and measurement of successful ageing vary both within and between disciplines; there is little interdisciplinary cross-referencing. Biomedical models emphasize physical and mental functioning as successful ageing, while sociopsychological models focus on social functioning, life satisfaction and psychological resources. Older people themselves adopt multifaceted definitions of successful ageing1,2 . Moreover, research shows that older people consider themselves to have aged successfully, but classifications based on traditional, narrower domain models do not1 – 3 . This suggests that a model of successful ageing needs to be multidimensional, cut across disciplines, and incorporate a lay perspective for social significance. Moreover, there is overlap, and lack of clarity, in the literature between concepts of successful ageing, active ageing and quality of life. Analysis of overlap between lay perceptions of these concepts in surveys using comparable methods showed that lay perceptions of active ageing emphasized striving to maintain health, functioning, and wider well-being (e.g. exercising the body and/or mind in order to maintain health and functioning), while lay definitions of successful ageing and quality of life focused on the existence of a state, rather than the striving for its achievement (e.g. the having health and ability per se 4 ). This distinction is consistent with the literature on active ageing, which portrays quality of life, and also having ‘successfully aged ’, as the end points, although ‘successful ageing’ can also be viewed as a dynamic process. An earlier interdisciplinary systematic review of the literature by this author1,3 found that the most common definitions of successful ageing were based on theories of social functioning, life satisfaction, psychological resources and biomedical approaches. A small body of literature focused on lay views. The distinction between concepts as either predictor or constituent variables was not always clear. The survey with the highest citations for successful ageing was the MacArthur Foundation studies of successful ageing5 – 7 , which are based on a biomedical model, broadened to include active engagement with life.
Social functioning has been conceptualized and measured in many different ways, including social engagement, social roles, participation and activity, social contacts and exchanges, and/or positive social relationships. The main theoretical approaches relating to successful ageing and social functioning are disengagement, activity and continuity theories, although each suffers from limitations, and all are now outdated (see Bearon for critique8 ).
LIFE SATISFACTION A smaller number of authors included life satisfaction, well-being or their elements in their conceptual and empirical definitions of successful ageing. Components of life satisfaction include zest, resolution, fortitude, relationships between desired and achieved goals, self-concept and mood, including happiness9 – 11 . Havighurst11 (p. 305) stated, ‘a person is aging successfully if he feels satisfied with his past and present life’, thus arguing that life satisfaction is an attribute of successful ageing, although others have argued that it is a condition for its achievement. Feelings of well-being were an outcome indicator of successful ageing in the Berlin Aging Study12 . There is lack of consistency about the status of life satisfaction, in particular, as an indicator or constituent variable.
PSYCHOLOGICAL RESOURCES Few investigators have included psychological resources as their study definition of successful ageing, and again it was not always clear whether the concepts used were predictor or constituent variables. Psychological models include possession of the resources of personal growth, creativity, self-efficacy, autonomy, independence, effective coping strategies, sense of purpose, self-acceptance and self-worth. These models have been criticized for their emphasis on autonomy, thus marginalizing frail older people13 . Baltes and colleagues14 developed a strong theoretical model based on the need to employ compensatory strategies when facing the dynamic between challenges and depleting reserves: selective
Principles and Practice of Geriatric Psychiatry, 3rd edn. Edited by Mohammed T. Abou-Saleh, Cornelius Katona and Anand Kumar 2011 John Wiley & Sons, Ltd
NORMAL AND ABNORMAL AGEING optimization with compensation (SOC). With this model, it is proposed that individuals can contribute to their own successful ageing: when selected activities can no longer be performed, strategies are needed to find new ones, and to maximize reserves. There is some supportive evidence from the Berlin Aging Study that people who use these strategies have better well-being than others12 . Ryff’s theoretical model of successful ageing emphasizes a life course approach, and holds that a developmental focus is required15,16 . She argues that successful ageing includes ‘positive or ideal functioning’ and is related to development over the life course. Fisher17 also emphasized adaptability and coping, and defined successful ageing as an ability to continue to grow and learn by using past experiences to cope with present circumstances and set goals for development.
BIOMEDICAL THEORIES Biomedical or decline theories generally define successful ageing as the optimization of life expectancy, while minimizing physical and mental deterioration. The MacArthur Foundation in the USA commissioned a major study of successful ageing led by Rowe, which comprised a three-site longitudinal study of adults living in the community aged 70–79 in 1988. It was rooted in Rowe and Kahn’s5 – 7 model of successful ageing as absence, or avoidance of, disease and risk factors; maintenance of physical and cognitive functioning; and active engagement with life (with others and in productive activities). They made the distinction between ‘usual ageing’, which describes normal decline in physical, social and cognitive functioning with age, and ‘successful ageing’, in which physiological and cognitive functional loss is minimized, there is active engagement with life, and capabilities even enhanced. This only partly recognizes heterogeneity among older people, and criticisms of Rowe and Kahn’s model include its narrowness, neglect of life course dynamics, failure to address adaptation to disease, and neglect of those who are incapacitated who cannot age successfully by the criteria used. A small number of studies have used elements of both biomedical and psychosocial approaches.
LAY VIEWS OF SUCCESSFUL AGEING Lay views are important to investigate in order to ensure that models of successful ageing have social significance, and to minimize the danger that definitions reflect mainstream cultural expectations and norms for the behaviour of older people. Without social significance, policy initiatives to enhance successful ageing are likely to fail. The systematic review of the literature, and empirical research by this author, illustrated that lay people view this concept multidimensionally, and included the following elements in their definitions: physical health and functioning; mental and cognitive health; psychological well-being and life satisfaction, including happiness; social functioning – relationships, support, activities and productivity; psychological resources, including personality, personal growth, accomplishments, sense of purpose, physical appearance, self-acceptance, coping, positive outlook, sense of humour; spirituality; lifestyles; neighbourhood; financial circumstances and security. It is also perceived as a dynamic concept. Von Faber et al.18 reported, from the Leiden longitudinal study of people aged 85+, that older people defined successful ageing as a process of adaptation rather than as a state of being, supporting psychological rather than biomedical models. Thus, investigations of older people’s views of successful ageing
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have indicated that they are far more multifaceted than existing models, crossing the boundaries between the physical, psychological and social self. Moreover, research shows that, overall, many older people consider themselves to have aged successfully while biomedical classifications do not categorize them so. Strawbridge et al.19 compared self-ratings of successful ageing among their sample members aged 65–69 from the longitudinal Alameda County Study with Rowe and Kahn’s three-factor model. They reported that, while half the sample could be categorized as having aged successfully with their own selfratings, only 19% could be so categorized with Rowe and Kahn’s model. Bowling’s further national survey of people aged 50+ living at home in Britain, asked people what they understood by the term successful ageing, then to rate the extent to which they had aged successfully2 . Two-thirds of respondents defined successful ageing in terms of having good health and functioning; almost half defined it psychologically. Others defined it mainly in relation to social roles and activities, social relationships, neighbourhood and local community. About four in ten (39%) respondents rated themselves as ageing successfully ‘Very well’, and a further 37% as ‘Well’, as opposed to ‘All right’, ‘Not well’ or ‘Not very well’ (see Figure 13.1). There were positive correlations between self-rated ageing successfully and good self-rated health, no reported longstanding illness, and good quality of life. There were no statistically significant associations with age. The main reasons people gave for their self-ratings of successful ageing included their physical and mental functioning, followed by psychological well-being, social relationships and financial circumstances1,2 . Also, while over a quarter indicated that they felt defiant about ageing when asked how they thought ageing would affect them, about 40% mentioned worse health and/or functioning, about a fifth thought they would be limited in their lives, and about 10% each mentioned worsening mental health and dependency (see Figure 13.2). In a further study, Bowling and Iliffe20 constructed and tested alternate biomedical, social, psychological and multifaceted lay-based models of successful ageing in a national population survey of people Are you ageing successfully so far? Yes, very well Yes, well Yes, all right No not well No, not very well
Figure 13.1 Self-rated successful ageing: national population sample aged 50+ in Britain. Data from the English Longitudinal Study of Ageing (Steel et al., 2004)
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PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRY the odds of mentioning social relationships (and vice versa). And respondents who defined successful ageing in terms of neighbourhood factors had almost twice the odds of also mentioning financial circumstances. The importance of these results is the demonstration that successful ageing is not perceived narrowly by lay people, in contrast to most theoretical models. It also illustrates the interaction between domains of life, e.g. social relationships may be needed for people to participate in social activities (to accompany people), and people see having both health and money as important for successful ageing.
50.0
Per cent
40.0 30.0 20.0 10.0 0.0 Worse Defiant Limitations Worse Dependency health/ on life mental functioning health
Figure 13.2 How do you think getting older will affect you? (Most common responses shown)
aged 65+ living at home in Britain. Respondents classified as successfully aged with the multifaceted lay model, compared to those classified as not successfully aged, had over five times the odds of rating their quality of life as good rather than not good. The comparable odds ratios from the other, single domain models, while significant, were considerably lower. Table 13.1 shows the associations between pairs of successful ageing themes mentioned by respondents. While the table shows several instances where mention of one definition was associated with reduced odds of mentioning another, it also indicates the multidimensionality of lay definitions. Respondents who defined successful ageing in terms of health had almost twice the odds, compared to those who did not, of also defining it in terms of finances. Respondents who mentioned social activity had almost twice the odds of mentioning social relationships (and vice versa), possibly reflecting the perceived need for companionship to undertake social activities (e.g. to accompany one on outings). Those mentioning social relations also had over twice the odds of mentioning finances, compared to those who did not. Similarly, respondents who mentioned finances had almost twice the odds of mentioning health and twice
CONCLUSION In conclusion, most authors in this field have made unwarranted conceptual leaps and assumed, often, that they have addressed ‘successful’ ageing with their chosen outcome indicators, with relatively few attempts at theoretical or conceptual justification. Rowe and Kahn’s three-factor biomedical model (including social elements) of successful ageing is the most popular and widely used in biomedical research, even outside the MacArthur studies of successful ageing5 – 7 . In contrast, lay models of successful ageing are more multidimensional, and, in particular, include more psychosocial elements. Also, to be realistic, the concept needs to be broadened, and to be seen on a continuum, rather than categorized dichotomously in terms of successful or unsuccessful. Also, given the inconsistency with which variables are used as either predictor or constituent variables in the study of successful ageing, advances could be made by grounding the term in older people’s definitions, and building on multidimensional theoretical approaches. Thus a definition of successful ageing would include longevity, physical, cognitive, psychological and social health and functioning, including effective coping, living circumstances (finances, neighbourhood) and overall life satisfaction. Precursors of effective coping strategies are likely to be possession of resources such as SOC, as hypothesized by Freund and Baltes (1998)12 . Using this approach, the different models are complementary to each other, and successful ageing is not only about maintaining good health and functioning, but it is also about coping and remaining in control of one’s life over the life-course, with the aim of achieving dynamically a status
Table 13.1 Logistic regression: associations (odds ratios; CI, confidence intervals) between successful ageing theme pairs (n = 854)a Themes (mentioned 1 versus not mentioned 0 = referent) (y): Themes (mentioned 1 vs. not mentioned 0 = referent) (x ): Health Psychological Social activity Finances Social relations Neighbourhood
Health Exp b (95% CI)
Psychological Exp b (95% CI)
Social activity Exp b (95% CI)
Finances Exp b (95% CI)
Social relations Exp b (95% CI)
Neighbourhood Exp b (95% CI)
–
0.713* (0.529–0.960) –
0.725** (0.534–0.983) 0.643** (0.478–0.866) –
1.915*** (1.355–2.706) 0.546*** (0.398–0.748) 0.703* (0.504–0.981) –
0.581*** (0.417–0.810) 0.539*** (0.387–0.751) 1.842*** (1.330–2.551) 2.001*** (1.417–2.825) –
0.903 (0.551–1.480) 0.744 (0.460–1.204) 0.980 (0.602–1.597) 1.981** (1.221–3.215) 1.000 (0.594–1.684) –
0.712** (0.528–0.959) 0.725* (0.534–0.983) 1.903*** 0.576*** (0.413–0.803) 0.912 (0.555–1.500)
0.639** (0.475–0.862) 0.543*** (0.396–0.745) 0.535*** (0.385–0.745) 0.755 (0.467–1.221)
0.694* (0.498–0.968) 1.839*** (1.327–2.547) 0.965NS (0.591–1.575)
2.004*** (1.421–2.826) 1.990** (1.231–3.217)
a Fully adjusted for age, sex and socioeconomic status; *p < 0.05; **p < 0.01; ***p < 0.001; NS not significant at 0.05 level.
1.008 (0.599–1.697)
NORMAL AND ABNORMAL AGEING of having successfully aged. Then the question of whether, and the extent to which, successful ageing is achievable can be addressed. Also, clinicians involved in the care of older people need to balance a dis-ease with a health and psychosocial perspective of older age, in order to enhance mutual understandings about desired treatment goals.
11.
12.
REFERENCES 1. Bowling A, Dieppe P. What is successful ageing and who should define it? Br Med J 2005; 331: 1548–51. 2. Bowling A. Successful ageing from older people’s perspectives. Results from a British survey of ageing. Eur J Ageing 2006; 3: 123–36. 3. Bowling A. Aspirations for older age in the 21st century: what is successful ageing? Int J Aging Hum Dev 2007; 64: 263–97. [Italian translation at www.geragogia.net.] 4. Bowling A. Enhancing later life: how older people perceive active ageing. Ageing Ment Health 2008; 12: 293–301. 5. Rowe JW, Kahn RL. Human aging: usual and successful. Science 1987; 237: 143–9. 6. Rowe JW, Kahn RL. Successful aging. Gerontologist 1997; 37: 433–40. 7. Rowe JW, Kahn RL. Successful Aging. New York: Pantheon. 8. Bearon LB. Successful aging: what does the ‘good life’ look like? Forum Fam Consum Issues (North Carolina State University) 1996; 1: 1–6. 9. Neugarten BL, Havighurst RJ, Tobin SS. The measurement of life satisfaction. J Gerontol 1961; 16, 134–143. 10. Vaillant GE. Avoiding negative life outcomes: evidence from a forty five year study. In Baltes PB, Baltes MM (eds),
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Successful Aging: Perspectives from the Social Sciences. New York: Cambridge University Press, 1990. Havighurst RJ. Successful aging. In Williams RH, Tibbits C, Donahue W (eds), Processes of Aging. New York: Atherton Press, 1963. Freund AM, Baltes PB. Selection, optimisation, and compensation as strategies of life management: correlations with subjective indicators of successful aging. Psychol Aging 1998; 13: 531–43. Nolan M. Successful aging: keeping the ‘person’ in personcentred care. Br J Nurs 2001; 10: 450–54. Baltes PM, Baltes MM (eds). Successful Aging: Perspectives from the Social Sciences. New York: Cambridge University Press. Ryff CD. Successful aging: a developmental approach. Gerontologist 1982; 22: 209–14. Ryff CD. Beyond Ponce de Leon and life satisfaction: New directions in quest of successful aging. Int J Behav Dev 1989; 12: 35–55. Fisher BJ. Successful aging: life satisfaction and generativity in later life. Int J Aging Hum Dev 1995; 41: 239–50. Von Faber M, Bootsma-van der Wiel A, van Excel E et al. Successful aging in the oldest old: who can be characterized as successfully aged? Arch Intern Med 2001; 161: 2694–700. Strawbridge WJ, Wallhagen MI, Cohen RD. Successful aging and well-being: self-rated compared with Rowe and Kahn. Gerontologist 2002; 42: 727–33. Bowling A, Iliffe S. Which model of successful ageing should be used in epidemiological surveys? Baseline findings from a British survey of ageing. Age Ageing 2006; 35: 607–14.
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Sexuality, Non-Traditional Relationships and Mental Health in Older People Ian Peate School of Nursing and Midwifery, Thames Valley University, London, UK
INTRODUCTION Despite an ageing population, little is known or understood about the sexual behaviours and sexual function of older people in society. Individuals (including the older person) manage their sexuality and sexual identity in a number of ways. Assumptions concerning ageing and intimacy in later life are now being challenged. Specific issues concerning sexuality and ageing will be discussed. In a minority of cases clinicians will be working more and more with older people who are involved in non-traditional relationships – a non-heterosexual context. Issues may arise for clinicians and older people concerning sexual identity. Many of those working with the older person will have had little training or education regarding nonheterosexual relationships and the older person. This chapter will emphasize the need to respect the fact that the expression of sexuality in older age is an important aspect of an individual’s being, as well as remembering that for some older people coming to terms with their sexuality may bring with it psychological distress. The chapter addresses the mental health of the older lesbian, gay and bisexual (LGB) person; issues concerning transgender and gender dysphoria will not be addressed here. A brief discussion concerning HIV and the older population has been included.
SEXUALITY AND AGEING Sexuality according to Ginsberg et al.1 is an activity of daily living that is important for a number of older people. Despite this, Edwards2 notes that within health care systems the sexual needs of the older person are often unrecognized and unmet, often as a result of negative attitudes and beliefs towards sexuality, sex and sexual desires. Many believe that these complex concepts can only be likened to youthfulness. Other factors can impinge on the individual’s ability to express freely their sexuality, for example, environmental (structure) constraints in long term care facilities may hinder an older person being able to express their sexual needs3 . Some common barriers to enjoying sex as a person ages are health problems or lack of a partner as opposed to lack of desire. Little research has been carried out with respect to stereotypical ideas about sex and ageing. Healthy people are often sexually active people and this has an impact on the quality of an individual’s life, therefore to deny an elderly person the option of being sexually active may result in dys-
function and distress. Among older adults there is an internal drive or need for sexual fulfilment4 . As people age the frequency in which they engage in sexual activity declines. Nevertheless, a substantial number of men and women engage in vaginal intercourse, fellatio, cunnilingus and masturbation, and some people remain sexually active in their eighties and nineties. The limited data that has been analysed demonstrates that there are some men and women who maintain sexual and intimate relationships and desires throughout their lives4 . Illness can seriously impede sexual activity but there is a dearth of literature regarding how illness impacts on the sexual activity of the older person. Altered pathophysiological changes often associated with the ageing process impact on sexual response in men and women, and most of the changes have a negative bearing on the person, both physically and psychologically. The loss of a partner as a person ages is common (particularly in older women). Problems associated with the sex act may be a precursor to problems related to an underlying illness such as diabetes mellitus, a genitourinary tract infection or cancer5 . There are a number of age-related changes in the vasculature and smooth muscle tissues involved in the erectile process as well as increased sensitivity to inhibitory signals in the smooth muscle6,7 . There are physiological changes that are associated with the menopause (these are complex); for example, a reduction in vaginal lubrication in response to a decrease in oestrogen levels. Attitudinal responses by society to postmenopausal women and their sexuality may also lead to an increase in vulnerability to depression. Sexual problems for men can include difficulty in achieving or maintaining an erection, lack of interest in sex, climaxing too quickly, anxiety about performance and an inability to climax. For elderly women bothersome problems include lack of interest in sex, difficulty with lubrication, an inability to climax, disliking sex and pain – often felt at the vagina during entry4 . If problems associated with sexual activity are not treated or are left undiagnosed this may lead to depression or social withdrawal. There are also a number of medications that can result in sexual dysfunction that patients need to take for an ongoing physical or psychiatric illness. The result of sexual problems arising from the taking of prescribed medications may induce the person to stop taking them in an attempt to reduce the negative side effects related to them.
Principles and Practice of Geriatric Psychiatry, 3rd edn. Edited by Mohammed T. Abou-Saleh, Cornelius Katona and Anand Kumar 2011 John Wiley & Sons, Ltd
NORMAL AND ABNORMAL AGEING Bancroft et al.8 emphasize the effect of relationship factors and mental health (particularly with regard to women) as being more important predictors of sexual well-being than the physiological factors of sexual arousal and response. For a number of women (tentatively, this could also be said for some men) being in a relationship, the quality of that relationship and a partner’s sexual problems are more important than their sexual responsiveness. Bancroft et al.8 considered only heterosexual women in his study; further research is needed to consider the impact of relationships versus sexual responsiveness in the LGB population. Kellett9 suggests that counselling may allow a couple who are experiencing sexual problems to express their fears and inhibitions, with the therapist educating the couple about the normal changes that accompany ageing.
ISSUES OF CONSENT AND COGNITIVE IMPAIRMENT The law demands that both parties engaging in sexual relations must consent; this is equally true for the older person, who may have issues associated with cognitive impairment such as dementia. Sexual abuse is a criminal offence. Free will and capacity are germane to informed consent. It may be difficult to ascertain if a person who is cognitively impaired has the capacity to consent to sexual relationships and as such this renders that person vulnerable. There are several potential ethical and legal issues that may arise as a result of this (Mental Capacity Act, 2005). Assuming that a person with dementia cannot make decisions and consent to intimate relationships or that they are unable to comprehend the consequences of decisions associated with consent, sex is unacceptable. Dementia leads to a variety of changes in people’s lives and one area that receives little attention is in respect to sexual relationships. Dementia in the older person is common, as is drug-induced confusional state; these issues are discussed elsewhere in this text. In drug-induced confusional state, a review of current medication is needed. A feature of dementia is the development of several cognitive deficits that include memory impairment. These cognitive deficits can be so severe that they can cause impairment in social functioning, including the ability to consent freely to engage in sexual activity with another person. The deficits may also predispose the person to inappropriate sexual behaviour. Dementia can impact on the individual’s feelings, desires and needs; sexual behaviour and their ability to express intimacy can change. The clinician should explain to the person and others that these changes are not a reflection on any individual and that it is possible to express intimacy in other ways if their chosen way has changed. People with dementia can experience sudden changes associated with their ability to express their sexuality. A range of behaviours can occur depending on what aspect of the brain is affected; sexual interest may diminish or conversely it may increase; there may also be a change in the level of inhibition. Usually, sex for many people is a private affair; dementia has the potential to bring many private activities out into the open, revealing many private intimate thoughts, feelings and sexually charged actions; for example, inappropriate touching of self and others, undressing and using sexually loaded language. While these actions may be embarrassing for others, they can also be confusing and distressing for the older person with dementia. What may appear to be inappropriate sexual behaviour may have a number of diverse causes. The causes can be identified by analysis of antecedents, behaviours and consequences, thus providing the clinician with information that will inform the most appropriate
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intervention if needed. Staff may need training in respect to the management of inappropriate sexual behaviours and the most appropriate ways to help the individual, families and other staff.
MENTAL HEALTH OF LESBIAN, GAY AND BISEXUAL PEOPLE Older LGB people may experience mental health distress for a number of reasons unconnected with their sexuality, as is the case with older heterosexual people. There are, however, a variety of social factors that may have an impact on the lives of the older LGB person and hence their mental health. There are some personal and social characteristics that may further exacerbate mental distress, for example, ethnicity and disability. Little is known about the mental health of the LGB population in the UK and even less is known about the LGB older population. Evidence that has been collected suggests that anxiety, depression, self-harm and suicidal feelings are more common among the LGB population when compared with the heterosexual population10 . There are also higher rates of drug and alcohol misuse among LGB people. The LGB population has been found to have the highest levels of mental distress. The data cited here refers to the LGB population as a whole in the UK and not specifically the older LGB population; nevertheless, as with all populations, LGB people will age and become older LGB people and some of these findings may well reflect those of the older LGBs. The reasons underpinning these findings are complex and as yet not fully understood. Warner et al.10 note that poor mental health in the LGB population has often been linked to experiences of homophobia, discrimination and bullying. Older people are not immune to the effects of homophobic discrimination and bullying by society generally and by those who provide and plan health care.
HOMOPHOBIA AND HETEROSEXISM Homophobia could be defined as the unreasonable hatred, prejudice and fear of LGB people. Extreme forms of homophobic behaviour can manifest as bullying and physical attacks. Heterosexism – where a society or community is conditioned to expect everyone to live and behave as heterosexual people do – can have a subtle impact on a person’s self-esteem and self-image. There are a number of instances where homophobic and heterosexist behaviours exist in the provision of health care with the outcome being detrimental to the health and well-being of the older LGB person. Institutional homophobia relies on the promotion of heterosexuality as the norm and when health services are provided where policy provision has neglected to take account of the needs of LGB people. In these instances an individual’s sexuality has been seen as inferior to the dominant hegemony – the heterosexual. The health service, legal system and police force all have histories of institutionalized homophobia. There are a number of organizations that work with older LGB people who neglect to take into account the reality that not all service users are heterosexual. Some residential care homes and sheltered housing are often mixed sex and are usually set up in such a way that service provision is directed towards heterosexuals, neglecting or refusing to accept that some of their clientele may be lesbian, gay or bisexual. Homophobia can have an impact in a number of ways. Being lesbian, gay or bisexual is not in itself a mental health problem; however, coping with the consequences of homophobia can have damaging effects on the health and well-being of an LGB person.
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Warner et al.10 have demonstrated a possible correlation between levels of homophobia and mental ill health among LGB people. Levels of anxiety, self-harm and depression among participants in this study were higher than average among the LGB participants. Homophobic experiences include damage to property, physical attack and bullying.
OLDER LESBIAN, GAY AND BISEXUAL PEOPLE There is often little value in using rigid categories when describing who is old or older as these terms can include a number of different generations. There is the potential when using such descriptions that the person (or people) being described may be disempowered and as such the term should be used with caution and tact. For the majority of older LGB people, living their life predominantly in the twentieth century may have meant that being open about their sexuality would have resulted in oppression and abuse within the mental health services11 as well as from society. There may be a number of reasons why this occurred; for example, mental health services then reflected the homophobia of the wider society. The Local Government Act (1998) made it illegal for teachers to sanction homosexuality in schools and described gay family relationships as false; this Act was repealed in 2003. Homophobia was also given legitimacy within psychiatry and psychology; theories of mental health pathologised homosexuality. Homosexuality was seen as the cause and effect of a mental illness or even as a mental illness itself. Damaging aversion therapies were often used regularly during the 1960s and 1970s to try to ‘cure’ homosexuality. Homosexuality was not officially struck off the UK government’s list of psychiatric disorders until 1993. Change is on the horizon and a number of legislative modifications have occurred to combat institutional homophobia in the UK. LGBs are now legally protected from discrimination associated with their sexual orientation from providers of goods and services; this also includes those who provide mental health services. There are some problems that remain. Some people who use mental health services and counselling or psychotherapy services are still being discriminated against with regards to their sexuality, and in some cases this is further exacerbated because of their age. The key factor for such discrimination is associated with lack of awareness among clinicians and due in part to ignorance as opposed to malevolence. A systematic review has been undertaken by the British Association for Counselling and Psychotherapy into the experiences of LGB people who have received counselling or psychotherapy services12 . Gaps in knowledge have been identified as well as revealing negative attitudes among some therapists. The review recommends that these gaps should be addressed in the training and education of therapists. Caution must always be taken with reviews of mental health services and the needs of the LGB population, as the results may under-represent the actual number of LGB people taking part in or being included in studies or reviews. There are some people who may be reluctant to disclose their sexuality and there may also be some discomfort and embarrassment on the part of the researcher in asking questions concerning sexuality and the older LGB person. As well as being lesbian, gay or bisexual, other characteristics such as age, ethnicity or disability can complicate or exacerbate an LGB person’s experience of mental illness. Attempts in the past to cure some older LGB people may have left these people with feelings of guilt accompanied with emotional damage. There may be a number of older people who have never acknowledged to themselves or others that they are lesbian, gay or bisexual.
Negative societal attitudes towards sexuality in older age can also have detrimental effects on a person’s health and well-being. Older people are often seen as unattractive and socially uninteresting. The ‘gay scene’ is generally geared towards meeting the needs of the younger LGB population. Lack of social opportunities can deny older LGB people the chance to meet other older LGB people; social isolation may ensue. Harmful societal attitudes can impact on communication between the physician and the patient. The outcome may be an unwillingness of patients and physicians to initiate discussion concerning sex.
HIV INFECTION IN OLDER POPULATION HIV infection in the older population has until recently in the main been ignored. Much of the published data regarding immunologic and clinical responses to highly active antiretroviral treatment (HAART) are associated with younger cohorts. The reasons why older people have for the most part been ignored are varied, and could include the risk of age related co-morbidity associated with clinical trials. With increased life expectancy and the success of HAART accompanied by an enhanced length of survival as a result of the improvement of the immunodeficiency caused by HIV infection, the number of older people with HIV is likely to continue to increase. As a result of this, clinical trials (research) that are age specific, taking into account the needs of the older person (i.e. considering co-morbidity and potential drug interactions) are required in relation to the impact of HIV on this population, including therapeutic and clinical outcomes.
CONCLUSION There are a number of older people who are sexually active although little is known about their sexual activities, behaviours and attitudes. Sexual problems are widespread among the older sexually active population; these problems are rarely discussed with clinicians. A number of older people may become sexually inactive because of a variety of sexual problems – these may be physiological in origin or as a result of their sexuality and societal reactions. For some older people heterosexual and LGB sex may play an important part in their relationships and well-being; there are also some who do not see this aspect of their lives as crucial. There may be some older people who would benefit from the input of clinicians who are willing to broach what is sometimes seen as the embarrassing and taboo subject of sexuality and the older person. Evidence suggests that being able to express one’s sexuality is positively correlated with good physical and mental health. Allowing the older person to express their sexuality will enhance their health and well-being in a number of ways. For this to happen clinicians must encourage the older person to discuss the issues that concern them. However, for this to take place the clinician must first feel comfortable with their sexuality and challenge any stereotypes they may have that concern the older person’s sexuality.
REFERENCES 1. Ginsberg TB, Pomerantz SC, Kramer-Feeley V. Sexuality in older adults: behaviours and preferences. Age Ageing 2005; 34(5): 475–80. 2. Edwards DJ. Sex and intimacy in the nursing home. Nurs Homes Long Term Care Manag 2003; 52(2): 18–21.
NORMAL AND ABNORMAL AGEING 3. Bouman WP, Arcelus J, Benbow SM. Nottingham Study of Sexuality and Ageing (NoSSA I): Attitudes regarding sexuality and older people. A review of the literature. Sex Relatsh Ther 2006; 21(2): 149–61. 4. Lindau ST, Schumm LP, Laumann EO et al. A study of sexuality and health among older adults in the United States. N Engl J Med 2007; 357(8): 762–74. 5. Rosen RC, Wing R, Schneider S, Gendrano N. Epidemiology of erectile dysfunction: the role of medical comorbidities and lifestyle factors. Urol Clin North Am 2005; 32: 403–17. 6. Bancroft JHJ. Sex and ageing. N Engl J Med 2007; 357(8): 820–22. 7. Schiavi RC. Aging and Male Sexuality. Cambridge: Cambridge University Press, 1999. 8. Bancroft JHJ, Loftus J, Long JS. Distress about sex: a national survey of women in heterosexual relationships. Arch Sex Behav 2003; 32: 193–208.
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9. Kellett JM. Sexual disorders. In Copeland JRM, Abou-Saleh MT, Blazer DG (eds), Principles and Practice of Geriatric Psychiatry, 2nd edn. Chichester: John Wiley & Sons, 2002. 10. Warner J, McKeown E, Griffin M, Johnson K, Ramsay A. Rates predictors of mental illness in gay men and lesbians and bisexual men and women. Br J Psychiatry 2004; 85(6): 479–85. 11. Sayce L. Breaking the Link between Homosexuality and Mental Illness: An Unfinished History. London: Mind. 12. King M, Semlyen J, Killapsy H, Nazareth I, Osborn D. A Systematic Review of Research on Counselling and Psychotherapy for Lesbian, Gay, Bisexual and Transgender People. London: British Association for Counselling and Psychotherapy, 2007.
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The Care Home Experience Alisoun Milne School of Social Policy, Sociology and Social Research, University of Kent, Canterbury, UK
INTRODUCTION This chapter aims to highlight the key dimensions of the evidence base exploring the experience of living in a care home, with a particular focus on dementia. Despite the extent of recent policy and practice attention paid to care homes in both the UK and the US, surprisingly little is known about residents’ lived experience. Research is only now beginning to take account of the perspective of users with dementia and is embarking on the not inconsiderable task of developing tools and methodologies that can meaningfully capture their voices1 . By way of introduction, the broader context within which the care home experience is located is provided before moving onto the chapter’s core focus. Although much of the evidence presented is drawn from UK research, key messages are equally applicable to the US and mainland Europe.
Background In the United Kingdom about 5% of the total population aged over 65 lives in care homes. This is comparable with other European countries, the figure being slightly higher in Scandinavia2 . In the United States 4.2% of the 65 and over population live in nursing homes3 . In terms of absolute numbers, in 2007 420 000 people lived in care homes in the UK while in the US over 1.8 million people lived in nursing homes. It is important to note that US figures do not include ‘assisted living facilities’ whereas UK figures incorporate care homes that do not provide nursing carei as well as those that do. Care homes’ residents tend to be very elderly and frail; multiple physical problems and/or co-morbidity with mental disorders are common4 . Typically, UK residents are aged over 80 years, are female, have previously lived alone, are on a low income and have multiple disabilities. In a recent UK study of 16 000 residents, over half had dementia, stroke or other neurodegenerative disease, 78% had at least one form of mental impairment, 71% were incontinent and 76% needed help with mobility or were immobile5 ; 27% were immobile, confused and incontinent. It is estimated that over two thirds of people living in all UK care homes have dementia, most often in the advanced stage, and about a third of all care home i
The term ‘care home’ covers any establishment providing accommodation with personal or nursing care. There are broadly two types of care home: homes that provide nursing care (nursing homes) and homes that provide personal care and support (residential homes).
places are registered to provide specialist dementia care6 . In the US it is estimated that 23–42% of residential community/assisted living residents have moderate or severe dementia. Many residents with dementia experience behavioural problems such as activity disturbances (agitation), aggression and psychosis; reported prevalence of these so-called ‘challenging behaviours’ can be as high as 90%7 . In addition, an estimated 50% of all care home residents have depressive disorders that would warrant intervention8. Depression in care home populations is associated with functional impairment (e.g. sensory loss, incontinence, loss of mobility), physical health problems (notably pain, dysphasia and heart disease), and social problems such as loneliness9 . Due to the complexity of assessing the extent of depression among people with dementia and the limited evidence base, it has been suggested that depression in care home residents is often either under- or misdiagnosed10 . Anxiety symptoms are also relatively common; they are particularly associated with depression and stroke11 .
Living with Dementia in a Care Home Despite the predominance of older people with dementia in care homes, research that draws on the experience of this group of residents has only recently emerged. In part, this reflects the liminal status of people with dementia inside, and outside, the ‘care system’, as well as the genuine complexity of collecting data from people whose cognitive capacity and communication skills may be limited12 . It is notable that an accumulating body of evidence offers valuable insights into the subjective experience of living with early stage dementia. It is also increasingly accepted that people in the middle to late stages of dementia retain the capacity for emotional expression and many can reliably express preferences13 . As improving long term care for people with dementia is now a key policy priority in both the UK and US, the continuing marginalization of this pivotal perspective in both the practice and research arenas can no longer be justified14 . Currently, there are two main sources of evidence about ‘the care home experience’. One draws on practice-based work whose core aim is that of improving care. ‘Dementia care mapping’ (DCM) is the most prominent example of this type of work; its influence also extends into the realms of research and inspection (see below)1 . The second source is drawn from research that has attempted to capture the nature and dimensions of care home life ‘from the inside’ and/or through the eyes of carers15 . Predominantly this material is
Principles and Practice of Geriatric Psychiatry, 3rd edn. Edited by Mohammed T. Abou-Saleh, Cornelius Katona and Anand Kumar 2011 John Wiley & Sons, Ltd
NORMAL AND ABNORMAL AGEING gathered from observational or questionnaire-based studies, which provide valuable insights and include evidence about the experience of the person with dementia; work that focuses specifically on the subjective experience of users is a new addition to the research portfolio16 . These two areas of activity combine around the concepts of quality of life and quality of care, both pivotal to the experience of living with dementia in a care home. As quality indicators used by the Commission for Social Care Inspectionii,iii (CSCI) move to focus more on ‘outcomes of care’, taking account of the perspective of the person with dementia becomes increasingly important17 . A brief review of research findings about quality of life in care homes for people with dementia and ‘what is important’ to residents will be offered before turning to evidence about their lived experiences.
Quality of Life and Quality of Care Assessing quality of life among care home residents is a difficult task; it is a complex construct, which is variously measured and evaluated. A number of scales do exist, several of which have been specifically developed for people with dementia; these include the Quality of Life in Alzheimer’s Disease (QoL-AD)18 scale, the DEMQOL19 and the DQol20 . A persistent challenge in evaluating quality of life is that there are often differences between the ratings of staff, carers and residents. This appears to be a consequence of a difference in emphasis: a recent study found that residents’ quality of life scores were most affected by the presence of depression and anxiety, whereas staff ratings were associated with dependency and behaviour problems21 . A full picture of quality of life may thus require a combination of measures, incorporating the observations of all three groups22 . Despite the difficulties associated with measurement, evidence to date suggests that quality of life in care homes is largely determined by the existence of mental health problems and subjective well-being11 . Systematic assessment of residents’ needs, and consideration of whether or not they have been met, has been suggested as a means of improving quality of life. The Camberwell Assessment of Need for the Elderly has been used towards this end23 . Limited consensus also exists in relation to the linked concept of quality of care. First – as with quality of life – there are multiple perspectives to be accommodated. Second, the components of ‘care’ include those elements that are provided within the home as well as those offered by external sources, such as medical care. Third, good quality care depends on a range of micro level (satisfied staff) and macro level (financial stability of the provider) factors and their interaction; this make its assessment complex and multifaceted. An important contribution to this field has been the development of DCM, an observational approach where items recording residents’ activity can be combined to calculate a care index score24 (see Chapter 30 for details on DCM). Given the limitations of all approaches to gathering information about quality of life and quality of care, an approach that accommodates multiple methods is recommended, rather than relying on a single source of evidence25 . As might be expected, evidence about the quality of care in homes is mixed. Some of the variation between studies results ii The CSCI has responsibility for monitoring standards in care homes. In April 2009, the CSCI was replaced by the Care Quality Commission. iii Regulatory bodies are established in each UK country to apply and monitor care standards: in England, it is the Care Quality Commission; in Wales, the Care Standards Inspectorate; and in Scotland, the Care Commission.
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from methodological differences. For example, studies adopting a ‘checklist’ approach tend to reach more positive conclusions than those using direct observations26 . There is more robust evidence in relationship to those issues that impact negatively on user quality of life. These include prescribing patterns and covert administration of medication, physical restraint, electronic tagging and abuse27 . In terms of therapeutic care practice, a recent survey undertaken by the Alzheimer’s Society28 of 4 084 family carers, and care home workers and managers found that people with dementia are not always afforded dignity and respect. ‘Dementia’ had become a label that subsumes all other needs and submerges the person’s characteristics; this tendency undermines the delivery of individualized care and encourages a task-oriented approach. Lack of activity and stimulation were also highlighted, particularly for people with severe dementia. As the availability of activities and opportunities for occupation is a major determinant of quality of life affecting depression, physical function and behavioural symptoms, this is a primary concern. A 2007 CSCI17 inspection of care homes for people with dementia echoes a number of these themes. Although the inspectors found some excellent examples of one-to-one attention and care offered with warmth, understanding and tolerance, impersonal assistance was widely in evidence. The report noted that quality of staff communication with residents – both verbal and non-verbal – had a significant impact on well-being. Positive communication that is warm and friendly results in the person with dementia feeling happy and relaxed. Conversely, negative or neutral communication – interactions that are impersonal or task focused – leave residents feeling distressed and withdrawn. It is thus evident from this and other CSCI inspections that residents with dementia do not always receive person-centred care – care which is delivered in ways that promote independence and which draw on the individual’s life course and experiences. It is to the role of experience in extending understanding of the person with dementia’s life in a care home that we now turn.
Evaluating the Experiences of the Person with Dementia Structured observational methods developed specifically for evidencing quality in long term care settings have a sustained history. They provide an opportunity to include the perspective of the person with dementia by collecting data on their experiences in communal areas, how they spend their time, and how they are treated. The most widely used dementia-specific observational tool is DCM. Kitwood, who developed the early prototype of DCM, described it as ‘a serious attempt to take the standpoint of the person with dementia, using a combination of empathy and observational skill’ (p. 4)29 . DCM requires training to employ but even with a standardized training programme the inter-rater reliability of practitioners is not high; those who use DCM for research purposes can achieve good reliability22 . A linked example of an observational tool is the Short Observation Framework for Inspection (SOFI). This draws heavily on DCM and involves structured observation of a sample of five residents in a communal area and over an extended lunch period17 . As part of an overall inspection, SOFI adds observational depth and detail. More recently video and digital recordings have also been used in care settings30 . They can provide fine-grained analysis enabling in-depth observation to occur. Video evidence can be particularly valuable when working with people with very advanced dementia whose speech on first listening seems meaningless, but on repeated replay shows clear attempts at communication31 .
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The extent to which selfhood or identity is preserved in people with dementia has been a key focus of observational studies32 . Results suggest that although the self is affected by dementia, manifestations of selfhood persist even in late stages of the illness along with the capacity to develop positive relationships33 . Questionnaire-based studies have also begun to address this issue, concluding that aspects of identity, as with selfhood, are retained by people with advanced dementia34 . Research also identifies recurrent issues of loss, communication difficulties, frustration and sadness among residents along with lack of meaningful occupation. Minimal levels of well-being are widely noted in many studies of care homes; these are particularly pronounced for people with the greatest dependency needs35 . Very recently attempts to explore the subjective experiences of people with advanced dementia in long term care have been made. A seminal study by Clare et al.16 provides an interpretive phenomenological account of the subjective, psychological experience of living with moderate to severe dementia in a care home. The thematic account highlights four interrelated experiences (see Table 15.1). Daily experience was shaped by the losses resulting from dementia for most residents and was characterized, to a considerable degree, by distressing thoughts and feelings. The psychological impact of ‘being in the home’ was associated with a sense of uncertainty, lack of control and limited self-determination. These feelings were compounded by multiple experiences of loss – lost abilities, lost memories, and lost identity – which resulted, for some, in feelings of worthlessness. Fear of ‘being alone’ or ‘being lost’ was also a dominant experience. However, through their accounts the residents emerged as ‘agents actively seeking to cope with their situation’ (p. 718). Many found ways to contribute and focused on the positive aspects of home life, including being part of supportive relationships. Such relationships appeared to be pivotal to maintaining a sense of well-being; their absence contributed to feelings of distress and alienation36 . Although participants displayed many constructive ways to cope, the effects of changes resulting from dementia, coupled with the context of institutional care, placed severe limitations on their expression of personal agency. Consequently, some residents experienced frustration, anger and boredom, especially around minimal activity and daily occupation37 . Lack of freedom and independence was experienced by some residents as ‘restrictive’ and communal living could give rise to considerable confusion. If we are serious about addressing current deficits in care home provision, understanding the subjective experience of people with dementia is a fundamental dimension of enhancing practice and thereby improving both quality of life for
Table 15.1 Key themes from the study of Clare et al.16 Nothing’s right : isolation, alienation, lack of choice, lack of control, fear, worthlessness I’ll manage: making the best of things, valuing contacts and friendships, finding ways of continuing to be useful, being accepted as you are, having a friend in the home, having links with relatives/family, acknowledgement of getting older I still am somebody: part of coping, affirming one’s sense of identity, managing well despite limitations It drives me mad : frustration and anger at the situation, confined, wanting more independence, boredom, lack of activity, annoying behaviour of other residents, uncertainty, fear, irritation
users and quality of care. The implications of this shift in emphasis are the focus of the final section.
IMPLICATIONS FOR PRACTICE: ENHANCING QUALITY OF LIFE IN CARE HOMES Much of the evidence reviewed above identifies an overarching need to embed person-centred values into care planning and delivery in care home settings. The pivotal role of developing meaningful relationships and an emphasis on effective communication appear to be the twin routes to enhancing well-being in residents with dementia38 . There is a related need to address a number of practical and therapeutic deficits. Extending levels of engagement for people with dementia by offering meaningful activities is a prominent example; supporting the continued expression of personal agency and autonomy is a secondary challenge39 . Managing the difficult and often negative emotions that many residents experience is also important; this depends on the establishment of genuine staff–resident relationships and the capacity of staff to respond sensitively and on an individual basis to need. Supporting role identity is another element of good care; this depends on staff engaging with residents’ life course and promoting opportunities for residents to have a continued social role. Being aware of the challenges of living a semi-public life in an institutional setting is an additional facet; this includes working with residents to deal with difficult relationships and providing opportunities for privacy16 . As noted above, evidence suggests that preservation of self and identity is possible even in those with advanced dementia. The maintenance of previous relationships with friends and relatives is key to providing biographical continuity. Moving into a care home tends to disrupt existing relationships, which may impact negatively on users’ sense of self, a process compounded by loss of independence40 . In this context the relevance of care that is truly person centred becomes clear and understanding what matters to an individual, including his or her wishes, is critical. Story-telling and biographical work can help to develop relationships between staff and residents; this not only increases the likelihood of the resident being seen and valued as an individual41 but also helps to maintain their cultural and ethnic identity. Recognition of residents’ emotional and social needs – in addition to their physical needs – is crucial to achieving person-centred care. Spending time engaging people with dementia ‘in conversation’ can also provide a powerful counterweight to the often task-oriented exchanges between residents and staff. It has been suggested that relationships are the key to maintaining well-being in people with dementia and that effective communication – the by-product of a good relationship – undergirds good quality dementia care42 . Some commentators even argue that caring for a person with advanced dementia is essentially about finding ways to communicate even when these may be unfamiliar. Meaningful interactions require the development of a set of core skills among staff: attentiveness, active listening, observation of non-verbal signs, and the use of personal objects to support communication43 . Staff can also enhance effective communication by ensuring that they face a resident when speaking, have light upon them rather than behind them, using gestures that are consistent with what they are saying, and presenting information simply and slowly44 . A part of this process is also supporting the ‘coping strategies’ the user has developed to manage the difficulties he or she encounters in the home. For many care staff, being able to effect meaningful communication with residents is a crucial component of job satisfaction; lack
NORMAL AND ABNORMAL AGEING of opportunity to build personal attachments is a strong predictor of staff burnout45 . This evidence suggests that enhancing communication skills – a widely noted practice deficit – needs to be a distinctive focus of dementia care training and that care homes need to find ways to ensure staff have the time and expertise to build up and sustain interactions with residents. It is important to recognize that providing care that takes residents’ emotional experiences and wishes seriously, facilitates choice and provides a sense of security and reassurance is both time consuming and intensive46 . A number of key characteristics mark out those care homes that successfully promote and sustain good quality care: clear leadership, a positive ethos, and staff training and support to enhance communication skills and promote retention47 . A recent project – the ‘Enriched Opportunities Programme’ – offered a multilevel approach to enhancing the quality of care in three care homes for people with dementia: it included a strong emphasis on leadership and dementia expertise, a trained care team with empathy for residents, and a programme of care and activity developed to meet the needs of individuals. It evidenced that by adopting a coherent focused approach that takes full account of the experiences of residents, care practice and the overall culture of care can be significantly improved48 .
CONCLUSION People with dementia living in care homes face enormous challenges. In addition to declining cognitive powers, users have to cope with a new and often unpredictable environment. They may also be cared for by people who know very little about them and who are, encouraged by an over-reliance on ‘procedures’, to focus on their physical safety rather than their emotional well-being. Additionally, frailty, communication difficulties and dependency on others often means that their needs are overlooked and their voices marginalized. Understanding more about the experience of living with dementia in a care home is a critical contribution to improving both quality of life and quality of care. Prioritizing relationships and communication, the establishment of genuine staff–resident attachment, managing distressing emotions, and ensuring that care is individually planned and delivered are key dimensions of practice that place the user experience at its core. Intimate biographical knowledge about the user and their life history, and bolstering the user’s abilities, sense of self and identity are key aspects of providing person-centred care. The provision of tailored day activities and recognition of the stresses communal life can cause are also important issues highlighted by research. Excellence in dementia care begins with an understanding of what it is like to live with the illness throughout its trajectory49 . As there is no doubt that residential care is, and will continue to be, one of the dominant types of provision for people with advanced dementia in the developed world, increased emphasis on research that explores the user experience and practice that foregrounds it, is a central component of effective and positive practice in care home settings.
REFERENCES 1. Brooker D. Quality: the perspective of the person with dementia. In Downs M, Bowers B (eds), Excellence in Dementia Care: Research into Practice. Open University Press, Milton Keynes, 2008, 476–91. 2. Organisation for Economic Co-operation and Development. Long-Term Care for Older People. Paris: OECD, 2005.
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3. Zimmerman S, Gruber-Baldini AL, Sloane PD et al . Assisted living and nursing homes: apples and oranges? Gerontologist 2003; 45: 105–17. 4. Alzheimer’s Society Dementia UK . London: Alzheimer’s Society, 2007. 5. Bowman C, Whistler J, Ellerby M. A national census of care home residents. Age Ageing 2004; 33: 561–6. 6. Matthews FE, Dening TR. Prevalence of dementia in institutional care. Lancet 2002; 360: 225–6. 7. Brodaty H, Draper B, Saab D et al . Psychosis, depression and behavioural disturbances in Sydney nursing home residents: prevalence and predictors. Int J Geriatr Psychiatry 2001; 16: 504–12. 8. Dening T, Milne A. Mental health in care homes for older people. In Jacoby R, Oppenheimer C, Dening T, Thomas A (eds), The Oxford Textbook of Old Age Psychiatry. Oxford: Oxford University Press, 2001. 9. Jones RN, Marcantonio ER, Rabinowitz T. Prevalence and correlates of recognized depression in US nursing homes. J Am Geriatr Soc 2003; 51: 1404–9. 10. Evers MM, Samuels SC, Lantz M et al . The prevalence, diagnosis and treatment of depression in dementia patients in chronic care facilities in the last six months of life. Int J Geriatr Psychiatry 2002; 17: 464–72. 11. Smallbrugge M, Pot AM, Jongenelis L et al . The impact of depression and anxiety on well being, disability and use of health care services in nursing home patients. Int J Geriatr Psychiatry 2006; 21: 325–32. 12. Dening T, Milne A. Depression and mental health in care homes for older people. Qual Ageing 2009; 10(2): 40–46. 13. Phinney A. Toward understanding subjective experiences of dementia. In Downs M, Bowers B (eds), Excellence in Dementia Care: Research into Practice. Milton Keynes: Open University Press, 2008, 35–51. 14. Department of Health. National Dementia Strategy. London: Department of Health, 2008. 15. Nolan M, Lundh U, Grant G, Keady J. Partnerships in Family Care. Milton Keynes: Open University Press, 2003. 16. Clare L, Rowlands J, Bruce E et al . The experience of living with dementia in residential care: an interpretive phenomenological analysis. Gerontologist 2008; 48(6): 711–20. 17. Commission for Social Care Inspection. See Me, Not Just the Dementia: Understanding People’s Experience of Living in a Care Home. London: CSCI, 2008. 18. Hoe J, Katona C, Roch B et al . Use of the QOL-AD for measuring quality of life in people with severe dementia – the LASERAD study. Age Ageing 2005; 34: 130–35. 19. Smith SC, Lamping DL, Banerjee S et al . Measurement of health related quality of life for people with dementia: development of a new instrument (DEMQOL) and an evaluation of current methodology. Health Technol Assess 2005; 9(10): 1–93, iii–iv. 20. Brod M, Stewart AL, Sands L, Watson P. Conceptualisation and measurement of quality of life in dementia: the dementia quality of life instrument (DQoL). Gerontologist 1999; 39(1): 25–35. 21. Hoe J, Hancock G, Livingston G et al . Quality of life of people with dementia in residential care homes. Br J Psychiatry 1999; 188: 460–64. 22. Sloane PD, Zimmerman S, Williams CS et al . Evaluating the quality of life of long-term care residents with dementia. Gerontologist 2005; 45(special issue 1): 37–49.
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23. Orrell M, Hancock G. CANE: Camberwell Assessment of Need for the Elderly. London: Gaskell, 2004. 24. Brooker D. Person-Centred Dementia Care: Making Services Better, Bradford Dementia Group Good Practice Guides. London: Jessica Kingsley, 2007. 25. Innes A, Kelly F. Evaluating long stay care settings: reflections on the process with particular reference to DCM. In Innes A, McCabe L (eds), Evaluation in Dementia Care. London: Jessica Kingsley, 2007. 26. Ballard C, Fossey J, Chithramohan R et al . Quality of care in private sector and NHS facilities for people with dementia: crosssectional study. Br Med J 2001; 323: 426–7. 27. Help the Aged and National Care Home Research and Development Forum. My Home Life: Quality of Life in Care Homes. London: Help the Aged, 2006. 28. Alzheimer’s Society. Home from Home. London: Alzheimer’s Society, 2007. 29. Kitwood T. Dementia Reconsidered: The Person Comes First . Milton Keynes: Open University Press, 1997. 30. Cook A. Using video observation to include the experiences of people with dementia in research. In Wilkinson H (ed.), The Perspectives of People with Dementia: Research Methods and Motivations. London: Jessica Kingsley, 2002. 31. Killick J, Allan K. The Good Sunset Project: making contact with those close to death. J Dement Care 2006; 14(1): 22–4. 32. Hubbard G, Tester S, Downs M. Meaningful social interactions between older people in institutional care settings. Ageing Soc 2003; 23: 99–114. 33. Williams CL, Tappen RM. Can we create a therapeutic relationship with nursing home residents in the later stages of Alzheimer’s disease? Journal of Psychosocial Nursing 1999; 37: 28–35. 34. Cohen-Mansfield J, Golander H, Arnheim G. Self-identity in older persons suffering from dementia: preliminary results. Soc Sci Med 2000; 51: 381–94. 35. Hubbard G, Cook A, Tester S, Downs M. (2002) Beyond words: older people with dementia using and interpreting nonverbal behaviour. J Aging Stud 2002; 16: 155–67. 36. Surr CA. Preservation of self in people with dementia living in residential care: a socio-biographical approach. Soc Sci Med 2006; 62: 1720–30. 37. Train GH, Nurock SA, Mandela M et al . A qualitative study of the experiences of long-term care for residents with dementia, their relatives and staff. Aging Ment Health 2005; 9: 119–28.
38. Fossey J, James I. Evidence Based Approaches to Improving Dementia Care in Care Homes. London: Alzheimer’s Society, 2008. 39. Cohen-Mansfield J, Parpura-Gill A, Golander H. Utilization of self-identity roles for designing interventions for persons with dementia. J Gerontol B Psychol Sci Soc Sci 2006; 61(4): P202–12. 40. Brown-Wilson C, Cook G, Forte D. The use of narrative in developing relationships in care homes. In Froggatt K, Davies S, Meyer, J (eds), Understanding Care Homes: A Research and Development Perspective. London: Jessica Kingsley, 2009, 70–90. 41. Brooker D. Person centred care. In Jacoby R, Oppenheimer C, Dening T, Thomas A (eds), The Oxford Textbook of Old Age Psychiatry. Oxford: Oxford University Press, 2008. 42. Robinson J, Banks P. Care Services Enquiry: The Business of Caring. London: King’s Fund, 2005. 43. Allan K, Killick, J. Communication and relationships: an inclusive social world. In Downs M, Bowers B (eds), Excellence in Dementia Care: Research into Practice. Milton Keynes: Open University Press, 2008, 212–29. 44. Adams T. From person-centred to relationship-centred care. Generations Rev 2005; 15: 4–7. 45. Moyle W, Skinner J, Rowe G, Gork C. Views of job satisfaction and dissatisfaction in Australian long-term care. J Clin Nurs 2003; 12(2): 168–76. 46. Davies S, Nolan M. Attending to relationships in dementia care. In Downs M, Bowers B (eds), Excellence in Dementia Care: Research into Practice. Milton Keynes: Open University Press, 2008, 438–54. 47. Commission for Social Care Inspection. The State of Social Care in England 2006–07 . London: CSCI, 2008. 48. Fossey J. Care homes. In Downs M, Bowers B (eds), Excellence in Dementia Care: Research into Practice. Milton Keynes: Open University Press, 2008, 336–58. 49. Phinney A. Toward understanding subjective experiences of dementia. In Downs M, Bowers B (eds), Excellence in Dementia Care: Research into Practice. Milton Keynes,Open University Press, 2008, 35–51.
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16
Ageing: International Statistical Trends and Prospects Fiona E. Matthews1 and George M. Savva2 1 MRC 2 Department
Biostatistics Unit, Institute of Public Health, Cambridge, UK of Public Health and Primary Care, Institute of Public Health, Cambridge, UK
INTRODUCTION The term ‘ageing’ is a generalized complex terminology that can address a number of concepts, including aspects such as the demography of the whole population or trends within specific age groups (such as births or the older population). But the term ‘ageing’ is also a generic term for the older population and factors associated with it. Within this chapter we aim to investigate some of these factors and show how the population of the world has changed, how historical changes will affect health in the next decades, how our estimates of population change are challenged by diseases and treatments and what can we currently say about the health of the older population.
Table 16.1 Percentage distributions of those aged 65 and older by region, 1950–2050 Region
1950
1975
2000
2025
2050
World 100 100 More developed regions 49.0 48.7 Less developed regions 51.0 51.3 Africa 5.5 5.4 Europe 34.4 33.5 Asia 43.9 43.6 North America 10.8 10.8 Latin America and the 4.7 6.0 Caribbean Oceania 0.7 0.7
100 40.7 59.3 6.2 25.6 51.6 9.3 6.7
100 31.5 68.5 6.8 17.8 57.9 8.7 8.1
100 21.7 78.3 9.4 12.1 62.1 6.4 9.4
0.7
0.7
0.6
TRENDS IN POPULATION SIZE The historic, current and future population demography demonstrates historic and interesting changes. Over the course of the last 50 years and in the next 50 years there has been and will be a fundamental shift in the distribution of the human population. Different areas of the world display different demographic shift patterns; for example the shifts in the United Kingdom and United States show patterns that are different from those seen in China and India1 . Nevertheless, all countries are experiencing population ageing. Figure 16.1 shows the demographic changes across different regions of the world. China and India have not only had a large change in the distribution of the population, they have also increased dramatically in size. The shift in this distribution means that the proportion of the population that is already considered ‘older’ varies greatly by country. Current estimates of the proportion of the population aged 60 years and over are shown in Figure 16.2. Although the relative distribution shifts from Europe and North America in 1950 towards Asia by 2050 (Table 16.1) there are large numbers in the older population throughout the whole world. Despite these differing demographic patterns already 64% of the older population (aged 60 and over) live in developing countries and by 2050 nearly 80% of those aged 60 and above will live in developing countries2 . This definition, however, includes only Europe, North America, Japan, Australia and New Zealand within the developed countries – a pattern that may not reflect true differences3 .
TRENDS IN FERTILITY Trends in fertility affect the composition of the older population many years later. While this ensures that surprises are not often encountered in the description of the older population it also means that demographic influences are less immediate at solving the challenges predicted. The decisions made on childbirth both between the two World Wars and after the Second World War are now shaping the composition of the older population. The generation of children to the ‘baby boomers’ in the 1960s are now reaching middle age and the size of this demographic bubble can be clearly seen in the population pyramids (Figure 16.1). Many European countries have for a number of years been below the reproductive factor (2.1 births per woman2 ). This rate of replacement of the younger population will again shift the relative balance of the population in terms of young and old. In this case there is a double impact, as the baby boomers reach old age with a lack of grandchildren to replace the status quo of the pyramid. This will create, at least for the next 50 years, an ageing society. The current fertility decisions of the early adults are not suggesting that this imbalance will refocus. In fact the decisions to delay or reduce childbirth across the whole of the developed population (and wider in many cases) mean that the majority of countries are now below the 2.1 factor.
Principles and Practice of Geriatric Psychiatry, 3rd edn. Edited by Mohammed T. Abou-Saleh, Cornelius Katona and Anand Kumar 2011 John Wiley & Sons, Ltd
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In the less developed regions where infant mortality is still high, despite advances resulting from the Millennium Development Goals (UN Millennium Goal 4), the fertility rate is still relatively high but is reducing dramatically. The developing countries are still experiencing an ageing population, but in a more historically understood way, although many unknowns remain4 . A recent UN report states that fertility levels are unlikely to rise again to the historic highs and therefore the expression of population ageing is irreversible5 . However future population size is sensitive to small but sustained deviations from the replacement level5 . The patterns of fertility affect not only the absolute level of the future middle-aged and older population but they also have a direct impact on the life of the older population at the individual level. The number of available carers within a population is almost universally linked to the extended family support. As this family structure shifts so will the life of the older person6 . An international comparative
UK
survey on the older population undertaken in 1996 showed that the proportion of the older population aged 60 and over living in threegeneration households was 29–43% in Asian countries compared with 2% for European and North American countries7 . If this structure is mimicked with the changing demographic then it will impact enormously on policy.
TRENDS IN LIFE EXPECTANCY AND HEALTHY LIFE EXPECTANCY ACROSS THE AGE RANGE There has been a steady and consistent increase in life expectancy at birth across all continents and in both males and females (Figure 16.3). However, the major issue in the statistical trends in healthy life expectancy is whether with the extension of longer life there is also an extension of healthy life (i.e. the total remaining life that can be expected to be free of disability). Three patterns of
100+ 95-99 90-94 85-89 80-84 75-79 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9 0-4
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Figure 16.1 Population pyramids and changing distribution. Bars refer to the size of the population (in thousands) of men (left) and women (right) in each age group
NORMAL AND ABNORMAL AGEING 100+ 95-99 90-94 85-89 80-84 75-79 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 5-9 0-4
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Figure 16.1 (continued )
population change in healthy life expectancy have been proposed, an expansion of morbidity8 , a compression of morbidity9 or dynamic equilibrium10 . Expansion of morbidity would imply longer life expectancy but at the same time longer life expectancy in ill-health, compression of morbidity would imply that the life extension is predominantly from the healthy life and dynamic equilibrium implies that severity may change, but the burden remains constant. Evidence to date suggests that all three scenarios can occur in different populations at different times.
MEASURING THE CHANGING HEALTH STATUS OF THE OLDER POPULATION Assessing the compression or expansion of morbidity relies on being able to measure the health status of the older population. Complementary insights regarding the changing health of the older population can be gained from several major sources, each with their own merits and drawbacks. In developed countries routinely gathered statistics such as census data and birth and death certification may be used and these provide reliable information on demographic changes. Routine
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20
15
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World
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.
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Percentage age 60 or older
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Oceania
Figure 16.2 Proportion of the older population by country medical databases, such as hospital admissions data, prescription records or disease registers provide another source. However the reporting of medical conditions to these registers may be biased by various processes. Both the mechanisms by which older people come to the attention of health care providers and reporting practices change with time, particularly in the older population, as a result of changing awareness, attitude and perception of health both by older people and their health care providers. Reporting practices can also vary geographically. Psychiatric conditions in the older population are particularly likely to be under-reported, and death certificates often do not mention major diseases such as dementia despite it being present or a major contributing factor to the death of an older person. Using routine data to record the health and in particular the psychiatric health of the older population is therefore unreliable. Furthermore in many areas of the world such statistics are not collected routinely. To overcome some of these methodological difficulties, epidemiological studies are conducted. These typically involve recruitment of a cohort who are chosen to be as representative of the population as possible, and these are then subjected to a standardized assessment of their health. Repeating standardized assessments in the same cohort over time leads to a longitudinal study in which changes in the health of the population can be examined. Longitudinal epidemiological studies of health are not without their difficulties. Biases in selection and drop-out are possible and must be examined carefully. Epidemiological studies often have limited applicability outside the populations in which they are conducted, and compared with routine statistics they are limited by their size in terms of detecting
small changes. Studies that rely on self-report may still be influenced by changing understanding or perceptions of health11 , or by cross-cultural differences in the interpretation of questions, and so questionnaires must be designed to be as objective as possible. Projections about the future burden of disease in the older population are generated by combining demographic data on the likely future numbers of older people with epidemiological data regarding disease prevalence and the impact of disease.
TRENDS IN GLOBAL HEALTHY LIFE EXPECTANCY The international patterns of disability and healthy life expectancy are not consistent with different patterns seen within different populations. Countries have reported both an increase in the prevalence of disability (Sweden12 ), rates stagnating (Australia13 ), or decreasing (United States14 , France15 , Finland16 , Japan17 ) and different evolutions reported for subgroups (men and women in Spain18 and Denmark19 ) or for mild rather than severe disability (Netherlands20 ). Trends in disability rates are not sufficient, however, as changes in the age distribution of the population need to be combined with the changes in the disability rates to see the full population, and hence conflicting results with another study from Australia found evidence of a compression of morbidity21 . A recent European comparison has shown that there are still large variations across Europe, and that these inequalities may be becoming larger, particularly between Eastern and Western Europe, and that healthy life expectancy may show more variations than life expectancy22 . In the developing world there is currently little evidence to investigate whether there is a compression of morbidity or an
NORMAL AND ABNORMAL AGEING
87
100 Males
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0 1950- 1955- 1960- 1965- 1970- 1975-1980- 1985- 1990- 1995- 2000- 2005- 2010- 2015- 2020- 2025- 2030- 2035- 2040- 20451955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010 2015 2020 2025 2030 2035 2040 2045 2050
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0 1950- 1955- 1960- 1965- 1970- 1975-1980- 1985- 1990- 1995- 2000- 2005- 2010- 2015- 2020- 2025- 2030- 2035- 2040- 20451955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010 2015 2020 2025 2030 2035 2040 2045 2050
Years of birth
Figure 16.3 Life expectancy at birth across world regions. From Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat1 . expansion23 . These countries are at the early stages of the chronic disease growth, though it is becoming an increasing problem. The challenge for a healthy older population across the entire world is one of a focus on lifelong health, not just health in mid to late life24 . This sort of focus is long term and often overlooked within a resource scarce environment. It is also possible that these different balances will fluctuate in different populations at different times and may well be modified by intervention strategies and changes to national care policies.
CHANGES IN MARKERS OF HEALTH As well as varying across cultures, whether the health of the older population is improving or worsening also depends on which measures of health are considered25,26 . Most studies of changes of health in the older population focus on changes in the levels of disabilities, since this is one of the major determinants of poor quality of life, the inability to live independently and the need for long-term care. Many such studies have shown improvements between cohorts with time. However, the level of disability of an
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PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRY
individual is determined both by their underlying health conditions leading to functional impairment and by their environment. Changes in levels of disability may therefore be caused by changes in lifelong exposure to risk factors affecting the prevalence of diseases, the changes in the impairments caused by diseases when they occur, and by changes in technology and the environment. Changes in the prevalence of health conditions may reflect both changes in incidence and in survival with that condition. The evidence regarding age-specific trends in disability in the older population is mixed. Some evidence of an improvement has been seen in the prevalence of mild disability, while the level of more severe disabilities has remained constant or has worsened slightly. In contrast, most comparisons of health conditions in the older population have shown an increase in major disease prevalence and co-morbidity as well as in objective measures of specific functional limitations12,27,28 . Consistent improvements in survival with diseases such as heart disease and stroke have not been offset by reductions in their incidence, leading to an increase in prevalence. On the other hand, disability among stroke survivors and those with heart disease has decreased. Although much of the increase in human life expectancy in the past century has been caused by a reduction in infant mortality, life expectancy of the older population is also increasing. This will lead to changes of the population structure within the older population, particularly in an increase in the numbers of the oldest old compared with the younger old29 . The oldest old are an emerging population group in terms of research and information on changes in their health and demographic characteristics are only beginning to become available. The oldest old have high rates of physical and cognitive impairment and are likely to live in institutions30. A recent report highlighted changes in the demographic and socioeconomic characteristics of the oldest old population in England and Wales31 , revealing an increase in the numbers of the oldest old living alone and as well as an increase in health care resource utilization. More research is needed on the oldest old.
CHANGES IN MENTAL HEALTH Mental health is increasingly recognized as a significant independent contributor to the burden of disease and as a mediator of aetiological factors for other diseases32 , and maintaining healthy brains in later life is now a research priority33 . Mental health issues such as schizophrenia and depression affect the whole population, and in the older population dementia and cognitive decline are of specific importance. Mental health in early and midlife is a strong predictor of mental health in old age. Little reliable evidence is available regarding trends in the prevalence of psychiatric conditions in the older population. A comparison of two studies with similar methodology carried out 10 years apart showed a significant increase in major depression diagnoses in all sociodemographic groups34 . The effect of changes in age structure of the global population on the number of people with dementia was estimated by a Delphi consensus study, which combined all the available evidence regarding dementia prevalence and future population trends35 . The number of people aged over 60 with dementia in Europe and North America is likely to have increased by 50% from 2001 numbers by 2020 and will have doubled or trebled by 2040. The numbers with dementia in East Asia and Africa are expected to increase by four times in this time period. There are projected to be 81.1 million people worldwide
with dementia in 2040 compared with 24.3 million in 2001, with 70% living in the developing world. However these estimates are based on limited information; while reliable estimates for dementia prevalence are available in the developed world, direct estimates are not available in many areas, although cross-cultural studies that have been undertaken suggest that patterns may be different and further information on global dementia epidemiology is urgently being sought. Changing incidence and survival with dementia and changes to the disability associated with dementia will affects its impact in the ageing population, and these trends will depend on changing prevalence of risk factors as well as interventions and management. The agespecific incidence of dementia and cognitive impairment has been suggested to have decreased slightly, possibly due to the effects of improved health-related lifestyle and education36 , while the increase in survival from stroke, might suggest an increasing prevalence37 . Social networks and intellectual stimulation are increasingly recognized as being important determinants of health and mental health in the older population. Models estimating the impact that changes in dementia trends and treatments will have on the future disability burden illustrate the uncertainty in predictions and highlight the need for treatments that will alleviate that burden38 .
FUTURE PROSPECTS AND DIRECTIONS International trends in ageing are difficult to predict, though recent publications have attempted to investigate not only the population shift5 , but also the trends in disability and health38 . However it is not just the population shift that requires careful consideration, other factors including changes in food, water, housing, education, early and midlife health and behaviour and the physical and biological environment will all affect our future health prospects39 . Trends seen across the world raise a number of concerns for the future of the ageing population, foremost of which are the increase in the burden of disease and dependency. Interdisciplinary research across the whole world and in all populations is required in both the ageing process of an individual and the effects of an ageing population, in order to understand and meet the challenges now and in the years ahead40 .
REFERENCES 1. Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat, World Population Prospects: The 2008 Revision, 2009. At http://esa.un.org/unpp, accessed 26 Mar 2009. 2. United Nations. World Population Prospects 2006 . At www.un.org/esa/population/publications/wpp2006/wpp2006.htm, accessed Mar 2009. 3. Kinsella K, Velkoff V, US Census Bureau. An Aging World . Washington, DC: US Government Printing Office, 2001. 4. Morgan S. Is low fertility a twenty-first-century demographic crisis? Demography 2003; 40: 589–603. 5. United Nations. World Population Ageing, 2007. At www.un.org/esa/population/publications/WPA2007/wpp2007.htm, accessed Mar 2009. 6. Ogawa N. Ageing trends and policy responses in the ESCAP region. In Population and Development: Selected Issues. Asian Population Studies Series No, 161. New York: United Nations, 2003, 89–127.
NORMAL AND ABNORMAL AGEING 7. Management and Coordination Agency. Brief Summary of the Fourth International Comparative Survey of the Elderly. Tokyo: Gyosei Printing Company, 1997. 8. Gruenberg EM. The failures of success. Milbank Mem Fund Q Health Soc 1977; 55: 3–24. 9. Fries J. Aging, natural death, and the compression of morbidity. N Engl J Med 1980; 303: 130–35. 10. Manton KG. Changing concepts of morbidity and mortality in the elderly population. Milbank Mem Fund Q Health Soc 1982; 60: 183–244. 11. Wolf DA, Hunt K, Knickman J. Perspectives on the recent decline in disability at older ages. Milbank Q 2005; 83: 365–95. 12. Parker MG, Ahacic K, Thorslund M. Health changes among Swedish Oldest old: prevalence rates from 1992 and 2002 show increasing health problems. J Gerontol A Biol Sci Med Sci 2005; 60: 1351–55. 13. Davis E, Beer J, Gligora C, Thorn A. Accounting for change in disability and severe restriction, 1981–1998. Australian Bureau of Statistics Working Paper 2001. 14. Freedman VA, Martin LG, Schoeni RF. Recent trends in disability and functioning among older adults in the United States: a systematic review. JAMA 2002; 288: 3137–46. 15. Robine J, Mormiche P, Sermet C. Examination of the causes and mechanisms of the increase in disability-free life expectancy. J Aging Health 1998; 10: 171–91. 16. Aij¨ansepp¨a S, Notkola I, Tijhuis M, van Staveren W, Kromhout D, Nissinen A. Physical functioning in elderly Europeans: 10 year changes in the north and south: the HALE project. J Epidemiol Community Health 2005; 59: 413–19. 17. Schoeni RF, Liang J, Bennett J, Sugisawa H, Fukaya T, Kobayashi E. Trends in old-age functioning and disability in Japan, 1993–2002. Popul Stud (Camb) 2006; 60: 39–53. 18. Sauvaget C, Tsuji I, Haan M, Hisamichi S. Trends in dementiafree life expectancy among elderly members of a large health maintenance organization. Int J Epidemiol 1999; 28: 1110–18. 19. Brønnum-Hansen H. Trends in health expectancy in Denmark, 1987–1994. Dan Med Bull 1998; 45: 217–21. 20. Perenboom RJM, Van Herten LM, Boshuizen HC, Van Den Bos GAM. Trends in disability-free life expectancy. Disabil Rehabil 2004; 26: 377–86. 21. Doblhammer G, Kytir J. Compression or expansion of morbidity? Trends in healthy-life expectancy in the elderly Austrian population between 1978 and 1998. Soc Sci Med 2001; 52: 385–91. 22. Jagger C, Gillies C, Moscone F et al . Inequalities in healthy life years in the 25 countries of the European Union in 2005: a crossnational meta-regression analysis. Lancet 2008; 372: 2124–31. 23. Kalache A, Keller I. The greying world: a challenge for the twenty-first century. Sci Prog 2000; 83: 33–54. 24. Kalache A, Aboderin I, Hoskins I. Compression of morbidity and active ageing: key priorities for public health policy in the 21st century. Bull World Health Org 2002; 80: 243–44.
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25. Parker MG, Thorslund M. Health trends in the elderly population: getting better and getting worse. Gerontologist 2007; 47: 150–58. 26. Crimmins EM. Trends in the Health of the Elderly, 2004. At: http://arjournals.annualreviews.org/doi/full/10.1146/annurev .publhealth.25.102802.124401?cookieSet=1, accessed Mar 2009. 27. Jagger C, Matthews R, Matthews F et al ., the Medical Research Council Cognitive Function and Ageing Study (MRC-CFAS). Cohort differences in disease and disability in the young-old: findings from the MRC Cognitive Function and Ageing Study (MRC-CFAS). BMC Public Health 2007; 7: 156. 28. Perenboom RJM, van Herten LM, Boshuizen HC, van den Bos GAM. Life expectancy without chronic morbidity: trends in gender and socioeconomic disparities. Public Health Rep 2005; 120: 46–54. 29. Robine J, Michel J, Herrmann FR. Who will care for the oldest people in our ageing society? BMJ 2007; 334: 570–71. 30. Xie J, Matthews FE, Jagger C, Bond J, Brayne C. The oldest old in England and Wales: a descriptive analysis based on the MRC Cognitive Function and Ageing Study. Age Ageing 2008; 37: 396–402. 31. Tomassini C. The oldest old in Great Britain: change over the last 20 years. Population Trends (Lond) 2006; 12332. 32. Prince M, Patel V, Saxena S, Maj M, Maselko J, Phillips MR, Rahman A. No health without mental health. Lancet 2007; 370: 859–77. 33. Brayne C. The elephant in the room – healthy brains in later life, epidemiology and public health. Nat Rev Neurosci 2007; 8: 233–39. 34. Compton WM, Conway KP, Stinson FS, Grant BF. Changes in the prevalence of major depression and comorbid substance use disorders in the United States between 1991–1992 and 2001–2002. Am J Psychiatry 2006; 163: 2141–47. 35. Ferri CP, Prince M, Brayne C et al . Global prevalence of dementia: a Delphi consensus study. Lancet 2005; 366: 2112–17. 36. Llewellyn D, Matthews F. Increasing levels of semantic verbal fluency in elderly English adults. Neuropsychol Dev Cogn B Aging Neuropsychol Cogn 2009; 1–13. 37. Ukraintseva S, Sloan F, Arbeev K, Yashin A. Increasing rates of dementia at time of declining mortality from stroke. Stroke 2006; 37: 1155–59. 38. Jagger C, Matthews R, Lindesay J, Robinson T, Croft P, Brayne C. The effect of dementia trends and treatments on longevity and disability: a simulation model based on the MRC Cognitive Function and Ageing Study (MRC CFAS). Age Ageing 2009; afp016. 39. Cohen J. Human population: the next half century. Science 2003; 302: 1172–75. 40. Franco O, Kirkwood T, Powell J, Catt M, Goodwin J, Ordovas J, van der OF. Ten commandments for the future of ageing research in the UK: a vision for action. BMC Geriatr 2007; 710.
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Economics of Ageing and Mental Health Anders Wimo KI Alzheimer’s Disease Research Center, Department of Neurobiology, Care Sciences and Society, Karolinska institutet, Stockholm, Sweden
INTRODUCTION The greying of the world and the high prevalence of mental disorders have highlighted the vulnerability of the social and health-care systems. Based on demographic forecasts, almost apocalyptic scenarios have been presented. The number of people 65 years and older will increase from about 500 million people in 2010 to about 1 billion in 2030. The diseases of the elderly and mental disorders are in general chronic, resource demanding, more or less incurable and long lasting (decades). These disorders also involve many sectors of the society; not only the health-care sector but also to a greater extent social services and informal carers, and they cause a substantial loss of well-being and life-years worldwide1 . If we also add a financial crisis in the many public care systems we must consider fundamental issues such as economic burden, cost effectiveness of treatments, priority settings, equity, how to organize, finance and distribute care in any health economics analysis. Health economics is the application of economic theory to health care2 . There are, however, several methodological issues in this field, which also link to fundamental health economics questions. Some basics in health economics must also be considered. The main focus in this chapter is on dementia and similar disorders, but the principles are applicable to any mental or chronic disorder and so we have also included examples from other mental conditions.
PERSPECTIVE A health economics analysis can be seen from different viewpoints such as a societal perspective or specific cost-bearers (e.g. county councils, municipalities, insurance companies)3 . A societal perspective is preferable and should include all relevant costs (that is both direct costs within the health sector and indirect costs due to production losses and costs of informal care) and outcomes. Depending on the selected viewpoint, the outcome of the analysis may vary.
the use of a resource in one specific way will result in some lost benefit because resources were not allocated to another option4 . Ideally, opportunity costs should be based on market prices, which in health care are not always easy to identify. For example, for an informal caregiver, who because of the care-cost demands is not working, the opportunity cost is the value of the forgone work that could have been done. Costs can be divided into direct medical costs, direct non-medical costs and indirect costs. In a simplified approach, direct costs refer to the value of resources used and indirect costs to resources lost. Direct medical costs refer to resources used in the medical care system, such as costs of hospital care, drugs and visits to clinics. Direct nonmedical costs are those outside the medical care system, such as costs for formal community care and transports. Depending on how care is organized, costs of long-term care and home care can be regarded as a medical or non-medical direct cost. Indirect costs are costs due to production losses (such as sick leave, early pension, impaired productivity) or mortality. Costs of informal care (see below) is a complicated issue in itself5,6 , and are often classified as indirect costs, but this is not always obvious. The costing process usually consists of two phases: first the use of resources is measured in terms of physical units (e.g. days in hospital, hours of home support) during a specified period of time; secondly, this resource utilization is calculated into costs. For economic studies of dementia, we have developed a process called resource utilization in dementia (RUD) (Table 17.1)11 . Because the organization of dementia care varies between countries, the process must be adapted to the particular national situation. This process also includes linguistic adaption, because the meaning and the costs of care concepts (such as ‘institutional care’) may vary between countries even if the basic language is similar, e.g. if English is spoken in the UK and South Africa, it does not necessarily mean that the interpretation of care concepts is the same. In multinational trials, it is recommended that the aggregation of results from different countries is in physical units and not in costs.
RESOURCE UTILIZATION AND COSTING A key issue in all economics is the cost concept. The opportunity cost, which most economists recommend using in descriptive studies and economical evaluations, is the value of a resource in its best alternative use2 . Care resources are more or less always scarce and
TYPES OF STUDIES Several approaches can be used in health economics analyses (see Table 17.2)7 . With the cost description (CD) approach, the costs of a single treatment are described without outcomes/effect measures
Principles and Practice of Geriatric Psychiatry, 3rd edn. Edited by Mohammed T. Abou-Saleh, Cornelius Katona and Anand Kumar 2011 John Wiley & Sons, Ltd
NORMAL AND ABNORMAL AGEING Table 17.1 Components of a resource utilization in dementia (RUD) plan38 Patient
Caregiver
Accommodation/long-term care (Work status) Respite care Hospital care Outclinic visits Social service Home nursing care Day care Drug use
Informal care time (for patient) Work status (Respite care) Hospital care Outclinic visits Social service Home nursing care Day care Drug use
Table 17.2 Different types of health economics studies CD CA CMA CEA CBA CUA CCA COI
Cost Cost Cost Cost Cost Cost Cost Cost
description analysis minimization analysis effectiveness analysis benefit analysis utility analysis consequence analysis of illness
and without making any comparisons with alternative treatments. In a cost analysis (CA), the costs of different treatments/therapies are compared, but there are no outcomes/effects included in the analysis. A complete health economics analysis should include both measurements of costs and outcomes and comparisons between different treatment alternatives. This is often expressed as a ratio: the the incremental cost-effectiveness ratio (ICER) C /E = (CA − CB )/((EAT1 − EAT0 ) − (EBT1 − EBT0 )) where C = costs, E = outcomes/effects, A,B = treatments, T0,T1 = time for assessments. There are, however, other approaches such as net benefit analyses (net monetary benefits and net health benefits)7 . Irrespective of approach, a willingness-to-pay level (for a specific outcome) is crucial. In a cost minimization analysis (CMA) there is evidence that the effects/outcomes are similar between the treatment options and thus the analysis is focused on identifying the therapy with the lowest cost. The difference between CA and CMA is that in a CA there is no data about effects/outcomes. In a cost-effectiveness analysis (CEA), the effect is expressed as a non-monetary quantified unit such as the cost per death or nursing home admission averted. Other outcomes may be functional measures such as activities in daily living (ADL) capacity, severity states of disease and cognition (e.g. scoring on different scales). In a cost benefit analysis (CBA), costs and outcomes are described in the same unit (usually monetary). Early CBA analyses had a simple human capital approach, while the modern theory of CBA is complex and includes willingness-to-pay approaches such as contingent valuation8,9 . In a cost utility analysis (CUA), the effect is expressed in terms of utilities, such as quality of life. In CUA, the concept of quality adjusted
91
life years (QALY) is frequently used (as well as other similar measures such as disability adjusted life years (DALY) and healthy years equivalents (HYE)). In a cost consequence analysis (CCA), cost and outcomes are analysed and presented separately and there is no direct mathematical connection between these two measures. Cost of illness (COI) studies are descriptive (such as the costs of illness of dementia in Sweden in SEK 50 billion/year). Two approaches can be used: the prevalence method and the incidence method. With the prevalence approach the costs include for all cases for a specified time period, most often one year, including those already suffering from dementia and for new cases occurring during the period in question10,11 . With the incidence approach the costs for new cases during e.g. one year are estimated, here both the annual costs and future (discounted) costs are included. The choice of approach depends on the purpose of the study: if the aim is to illustrate the economic consequences of interventions, the incidence approach is preferable. If the idea is to estimate the economic burden during a defined year the prevalence approach is the best option. Another issue in COI studies is whether to use a top-down or a bottom-up approach. In top-down analysis, the total costs for a specific resource (e.g. health-care costs) are distributed over different diseases. Such studies often rely on data from national registers or similar. The bottom-up method starts from a defined sub-population (often from a local area) with for example dementia and registers all cost of illness related to the disease, followed by an extrapolation to the total dementia population. The problem here is compensating for co-morbidity and net costs may be difficult to estimate. It is also important to specify the included cost categories (e.g. cost of informal care). COI studies can be expressed as costs per case and year or as total costs in a specific country/region. Examples of COI studies of mental disorders are seen in Table 17.3. The cost figures highlight the great variation in cost estimates and the importance of identifying the included cost categories.
INFORMAL CARE Family members and friends or others close to people with mental disorders are heavily involved in their care. Their situation is of great interest from two aspects. First, mental disorders have consequences for the carers themselves. In this sense, their situation is often very stressing (it can be described in terms of burden, coping, but also in terms of morbidity and mortality). Secondly, in their role as informal carers they are producers of unpaid care. This production of care is a very important part of the costs of mental disorders from a societal perspective. Costing of informal care is complicated and controversial. There are two frequently used methods: the replacement cost approach and the opportunity cost approach, both of which have drawbacks when applied to mental disorders. The replacement cost approach means that if informal care has not been provided, professional staff must be hired on a 1:1 ratio (e.g. one hour of informal care corresponds to one hour of professional care). In our opinion, informal care should be valued by its opportunity cost, which for a person of working age, is a production loss, but regarding leisure time and contributions by retired persons or persons with no position on the labour market, it is more complicated and there is no given answer. In most cases, the replacement cost approach results in higher costs of informal care than the opportunity cost approach.
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PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRY Table 17.3 Examples of COI studies of mental disorders Country/ Region
Disorder
World EU27 UK Sweden Europe Sweden Europe UK (London) Spain (Santander)
Dementia Dementia Dementia Dementia Depression Depression Psychosis/schizophrenia Schizophrenia Schizophrenia
Costs (billion US$ 2006)
Annual costs per patient (US$ 2006)
326.8 195.6 34.7 7.4 138.5 4.8 46.2 NA NA
11 138 26 761 47 847 52 095 5 016 NA 10 011 11 981 2 365
Cost categories included
Source
D, IC D, IC D, IND, IC D, IND, IC D, IND D, IND DC DC DC
(42) (43) (44) (45) (46) (47) (48) (49) (49)
D = Directs costs; IND = Indirect costs; IC = Costs of informal care Currency conversions by PPPs (purchase power parities), time transformations by national price index of health Sources: see39 – 41 .
Table 17.4 Randomized controlled trials with empirical economic data on pharmacological interventions in Alzheimer’s disease Drug
Disorder
Country
Duration
Results (US$ 2006)
Donepezil Donepezil
Alzheimer’s disease Alzheimer’s disease
1 year 6 months
1 228 (ns) 320 (ns)
(50) (51)
Donepezil Memantine Risperidone (r), olanzapine (o) and quetiapine (q)
Alzheimer’s disease Alzheimer’s disease Alzheimer’s disease
Nordic Canada France, Australia UK USA USA
60 weeks 6 months 9 months
−907 (ns) 7 946 (p < 0.05) (per month)2002, ITT 193(r),−9(o), −199 (q) Overall p = 0.02 (placebo lower)
(52) (53) (54)
BOOTSTRAPPING Cost data are often skewed (large variation in resource utilization and costs and lots of zero values), making traditional statistical analyses questionable. To compensate for these problems, bootstrapping is frequently used. By resampling from the original database, a new database is created. After each drawing from the original database to the new database, the drawn case is returned to the original database. There are many ways of bootstrapping but in general the new database has the same number of cases as the original sample. After repeating the resampling process several times (e.g. 100–10 000 times, using statistical software), statistical analyses, such as calculating confidence intervals, can be performed, assuming a better representativeness compared to the original reference population12 . Confidence intervals are often more narrow with bootstrapping than without.
OUTCOME MEASURES A health economics analysis is incomplete if there is no outcome/effectiveness measure related to the costs (mostly as a cost-effectiveness ratio). In mental disorders or diseases of the elderly, the choice of effectiveness measure is not obvious. The priority discussions may be between different treatments of a particular disease, but also between treatments of different diseases (e.g. schizophrenia and stroke). In the first situation, diagnosisspecific outcomes may be used (e.g. depression scales in depression,
Reference
cognition in dementia), but in the latter case, generic outcomes are necessary. Also when diagnosis-specific outcomes are used, there may be interpretation problems – what is the societal value of an incremental cost of X US$ for a one-point reduction in a depression scale? Health-related quality of life (HRQoL) is often suggested as the most relevant outcome measure in chronic disorders (such as mental diseases). HRQoL instruments consist of several dimensions (e.g. ADL, social interaction, cognition, perception, pain, anxiety, economic status) and they can be diagnosis-specific or generic13 . A specific problem in dementia and other mental disorders is that the subjective dimension may be difficult to measure. Thus, proxies (mostly caregivers) are often used14 . Indirect measurement per se, with proxies is, however, not necessarily a problem – the US Panel for cost effectiveness recommended that the general public should value health states15 . However, if the proxy is a family member, the answers may more or less reflect the situation and interests of the proxy and not the patient’s viewpoint. Examples of instruments used in dementia are the dementia quality of life instrument (DQoL)16 and quality of life – Alzheimer’s disease (QoLAD)17,18 . The quality of life assessment schedule (QoLAS) is an instrument that has been used in neuropsychiatric disorders19 – 21 . Since these instruments are not preference based15,22 , they are less appropriate for cost utility analysis. Generic HRQoL scales provide opportunities to make comparisons with other diseases. There are also two types of generic scales.
Depression
Netherlands
Netherlands
Dementia
Psychotherapy of 55+
Netherlands
Dementia
Case management Case management
Country
Disorder
Intervention
RCT + bootstrapping
RCT + bootstrapping RCT + bootstrapping
Design
Table 17.5 Economic evaluations with bootstrapping approaches
12 months
3 months
6 months
Study length
Recovery, QALYs
Successful treatment Successful treatment
Outcome
$798
$2 247*
$246*
Cost difference (US$ 2006*)
ICER 366 921/ recovery Intervention not cost effective
Dominance (94% probability)
4 315/unit
ICER in base option (US$ 2006)
95% vs. WTP of 34 000¤ 99% vs. WTP of ¤2000 per ‘successful treatment’ Bootstrapping: 17% more effective, less expensive. 35% more effective, more expensive, 37% less effective, more expensive. 11% less effective, less expensive
Sensitivity analysis or similar
(57)
(56)
(55)
References NORMAL AND ABNORMAL AGEING 93
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PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRY
Table 17.6 Examples of economic evaluations with modelling approaches Intervention
Disorder
Country
Design
Model length
Outcome
Cost difference (US$ 2006)
ICER in base option
Donepezil
Alzheimer’s disease Alzheimer’s disease Alzheimer’s disease Alzheimer’s disease
USA
Markov model Survival model AHEAD model Markov model
2 years
QALYs
92
Dominance
2 years
QALYs
438
10 years
QALYs
5 years
QALYs
Rivastigmine Galantamine Memantine
Canada UK Sweden
Examples of indexes or profiles are the sickness impact profile23 , the short form 36 (SF-36)24 and shorter versions; SF-20 and SF-12. Regarding caregivers, burden scales, such as the burden interview25 , can in some sense be used as indicators of QoL, but the interplay between patient characteristics, caregiver QoL and burden is complex26 . Other types of generic scales are used to calculate quality adjusted life years (QALY)27 . These include the health utilities index (HUI)22,28 , the EuroQoL/EQ-5D29 and the index of well-being/ quality of well-being scale (QWBS)30 . The QALY concept reflects both quantity of life and quality of life22,31 and is expressed as figures between 0 (death) and 1 (perfect health); it is widely used in CUA. The use of QALYs is under debate, particularly regarding the elderly32 . Chronic, incurable, progressive disorders may be disfavoured when compared with e.g. surgical treatment such as cataract or hip replacement surgery. Postponing institutional (long-term) care has sometimes been defined as an advantageous effect of interventions, making itself a potential outcome. However, this approach can be questioned for several reasons. The concept of institution is not homogeneous33 . There are also situations where institutional care is a better alternative that insufficient care ‘at home’. If postponing nursing home care is successful, there will also probably be a shift from formal care in an institution to formal home care but, which is more notable, also to an increased period of informal care. The latter shift may cause consequences on the caregiver’s private situation, and also from a societal cost perspective.
MODELLING Dementia and other mental disorders most often last for many years. The economic literature in this field with empirical data from interventions is often based on short periods of time. Such studies are shown in Tables 17.4 and 17.5 (Table 17.5 with bootstrapping approaches). The longest study period in these studies is 60 weeks. Since for practical reasons is difficult to perform interventions studies lasting for several years, there is a great interest in using different approaches of modelling to catch the long-term effects34 . In an economic model, results from a short empirical core period are extrapolated to a longer period. Inputs from several sources, e.g. efficacy, costing and progression, are used. Various applications of Markov models35 are frequently used, but several other approaches are at hand. In a review, Cohen and Neumann identified 13 types of models regarding Alzheimer’s disease36 .
Sensitivity analysis or similar
Reference
(58)
Dominance
<0 to 529 566 (all scenarios) NA
−817
14 755
9 861–29 585
(60)
13 454
Dominance
<0 in all scenarios
(61)
(59)
Discounting of costs (and perhaps outcomes) with rates between 3–5% is recommended15 . Examples of different modelling approaches are given in Table 17.6. Notable is that most models tend to indicate cost effectiveness. One reason is that the models are based on a positive efficacy effect of the active treatment and a relation between disease progression and costs. Factors that neutralize are the costs of the treatment itself (e.g. not only the drug but also diagnostics and laboratory tests that follow treatment), effects on mortality and costs of side effects. Models are controversial: the results are highly dependent on the assumptions. Long-term effects, such as exhaustion of carers and staff, which do not occur in the early stages of a disease, and symptoms which do have not a linear progressive course, such as behavioural and psychological symptoms in dementia (BPSDs)37 , are difficult to model. A model is also linked, implicitly or explicitly, to a specific organization of care. Although we regard modelling as an essential part of health economics, many drug authorities and clinical researchers are often sceptical about models; they regard such studies as not being ‘empirical’.
PHARMACOECONOMICS AND PROGRAMMES Even if the literature on health economics is sparse, there is a great deal concerning health economic evaluations of drug treatment. Other clinical interventions (here referred to as ‘programmes’) such as day care, caregiver support, psychotherapy, case management, housing programmes are common in the clinical reality, but sparse in the health economics literature of dementia and other mental disorders. There are several reasons for this. A drug intervention is rather easy to define and operationalize, while concepts such as ‘day care’ are more vague. Furthermore, it is difficult to include a sufficient number of study objects in an evaluation of a programme, resulting in poor statistical power. The basic field conditions (e.g. care structure, staff situation) at one study centre may differ considerably from another, making the intervention itself (e.g. day care) difficult to differentiate between different sites. In this sense a pill is much easier to define. The costs of a programme may also be very high if a lot of staff is involved and the economical strength of the sponsors is often weaker than the resources of drug companies.
CONCLUSION Due to the enormous socioeconomic impact of chronic disorders of the elderly (such as dementia and other mental disorders), it is
NORMAL AND ABNORMAL AGEING obvious that there is a great need to obtain information about ‘value for money’. Many clinicians take a position that it is unethical to discuss cost effectiveness of diseases that affect weak patient groups. Our position is the opposite: it is unethical NOT to discuss cost effectiveness of the treatment and management of these disorders. Care for these patients demands great investment and if we have no idea of what we get for the money, there is a great risk for a waste of money and resources. This is indeed unethical.
REFERENCES 1. Prince M, Patel V, Saxena S, Maj M, Maselko J, Phillips MR et al. No health without mental health. Lancet 2007; 370(9590): 859–77. 2. Drummond MF, O’Brien B, Stoddart GL, Torrance GW. Methods for the Economic Evaluation of Health Care Programmes. Oxford: Oxford University Press, 1997. 3. Winblad B, Hill S, Beermann B, Post SG, Wimo A. Issues in the economic evaluation of treatment for dementia. Position paper from the International Working Group on Harmonization of Dementia Drug Guidelines. Alzheimer Dis Assoc Disord 1997; 11(Suppl 3): 39–45. 4. Donaldson C, Mugford M, Vale L. Evidence-Based Health Economics. London: BMJ Books, 2002. 5. van den Berg B, Brouwer WB, Koopmanschap MA. Economic valuation of informal care. An overview of methods and applications. Eur J Health Econ 2004; 5(1): 36–45. 6. Jonsson L. Pharmacoeconomics of cholineesterase inhibitors in the treatment of Alzheimer’s disease. Pharmacoeconomics 2003; 21: 1025–37. 7. Drummond MF, Sculper MJ, Torrance GW, O’Brien BJ, Stoddart GL. Methods for the Economic Evaluation of Health Care Programmes, 3rd ed. Oxford: Oxford University Press, 2004. 8. Johannesson M, Johansson PO, Jonsson B. Economic evaluation of drug therapy: a review of the contingent valuation method. Pharmacoeconomics 1992; 1(5): 325–37. 9. Johannesson M, Weinstein MC. Designing and conducting cost-benefit analyses. In Spilker B (ed.), Quality of Life and Pharmacoeconomics in Clinical Trials, 2nd edn. Philadelphia: Lippincott-Raven, 1996. 10. Rice DP, Hodgson TA, Kopstein AN. The economic costs of illness: a replication and update. Health Financing Rev 1985; 7: 61–80. 11. Lindgren B. Costs of Illness in Sweden 1964–1975 . Lund: Liber, 1981. 12. Cameron CA, Trivedi PK. Microeconometrics using Stata. College Station: Stata Press, 2009. 13. Walker MD, Salek SS, Bayer AJ. A review of quality of life in Alzheimer’s disease. Part 1: Issues in assessing disease impact. Pharmacoeconomics 1998; 14(5): 499–530. 14. Stewart A, Brod M. Measuring health related quality of life in older and demented people. In Spilker B (ed), Quality of Life and Pharmacoeconomics in Clinical Trials. Philadelphia: LippincottRaven, 1996, 819–30. 15. Siegel JE, Torrance GW, Russell LB, Luce BR, Weinstein MC, Gold MR. Guidelines for pharmacoeconomic studies. Recommendations from the panel on cost effectiveness in health and medicine. Panel on cost Effectiveness in Health and Medicine. Pharmacoeconomics 1997; 11(2): 159–68.
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35. Sonnenberg FA, Leventhal EA. Modeling disease progression with Markov models. In Wimo A, Jonsson B, Karlsson G, Winblad B (eds), Health Economics of Dementia. Chichester: Wiley, 1998, 171–96. 36. Cohen JT, Neumann PJ. Decision analytic models for Alzheimer’s disease: state of the art and future directions. Alzheimers Dement 2008; 4(3): 212–22. 37. Ferris SH, Mittelman MS. Behavioral treatment of Alzheimer’s disease. Int Psychogeriatr 1996; 8(Suppl 1): 87–90. 38. Wimo A, Wetterholm AL, Mastey V, Winblad B. Evaluation of the resource utilization and caregiver time in anti-dementia drug trials – a quantitative battery. In Wimo A, Jonsson B, Karlsson G, Winblad B (eds), Health Economics of Dementia. Chichester: Wiley, 465–99. 39. Eurostat, 2009. At http://nui.epp.eurostat.ec.europa.eu/nui/show .do?dataset=prc_hicp_aind&lang=en. 40. ECB Statistical Data Warehouse, 2009 At http://sdw.ecb.europa .eu/browseTable.do?DATASET=0&CURRENCY=USD&node =2018794&SERIES_KEY=120.EXR.A.USD.EUR.SP00.A. 41. Data and Statistics, IMF, 2009 At http://www.imf.org/external /data.htm. 42. Wimo A, J¨onsson L, Winblad B. An estimate of the total worldwide societal costs of dementia in 2005. Alzheimers Dement 2007; 3: 81–91. 43. Wimo A, J¨onsson L, Gustavsson A. The cost of illness and burden of dementia in Europe. In Europe A (ed.), Dementia in Europe Yearbook 2008 . Luxembourg: Alzheimer Europe, 2008, 67–71. 44. Knapp M, Prince M. Dementia UK . London: Alzheimer’s Society, 2007. 45. Wimo A, Johansson L, J¨onsson L. Demenssjukdomarnas samh¨allskostnader och antalet dementa i Sverige 2005 [The societal costs of dementia and the number of demented in Sweden 2005] (in Swedish). Stockholm: Socialstyrelsen, 2007. 46. Sobocki PA, J¨onsson B, Wittchen HU, Olesen J. Cost of disorders of the brain in Europe. Euro J Neurology 2005; 12(Suppl 1): 1–27. 47. Sobocki P, Lekander I, Borgstrom F, Strom O, Runeson B. The economic burden of depression in Sweden from 1997 to 2005. Eur Psychiatry 2007; 22(3): 146–52. 48. Andlin-Sobocki P, Rossler W. Cost of psychotic disorders in Europe. Eur J Neurol 2005; 12(Suppl 1): 74–7. 49. Knapp M, Chisholm D, Leese M, Amaddeo F, Tansella M, Schene A et al. Comparing patterns and costs of schizophrenia care in five European countries: the EPSILON study. European Psychiatric Services: Inputs Linked to Outcome Domains and Needs. Acta Psychiatr Scand 2002; 105(1): 42–54. 50. Wimo A, Winblad B, Engedal K, Soininen H, Verhey F, Waldemar G et al. An economic evaluation of donepezil in
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18
The Influence of Social Factors on Mental Health Donna D. McAlpine1 and David Mechanic2 1 School
2 Institute
of Public Health, University of Minnesota, Minneapolis, USA for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, USA
Social factors have an enormous influence on the life course, affecting development and socialization; the relative influence of family and peers; opportunities for education, work, recreation, social participation and patterns of social integration; and independence as one reaches the later years of life. They also influence the availability of various health providers and health care settings if one seeks medical care. It is not surprising, therefore, that almost every aspect of mental health and well-being is influenced by social factors1 . Understanding the social context of mental illness requires appreciating how social factors may be causally related to either the first-onset or re-occurrence of mental illness, and, in turn, how individuals’ social circumstances are shaped by having a mental health problem early in life. Moreover, at all stages of the life course, social context and social policies help explain variation in response to symptoms, treatment patterns and outcomes. A life course perspective acknowledges that individuals carry into their later years all their prior experiences that influence health status as they age. Such a perspective also directs attention to cohort and historical differences in life circumstances and the experience of health and illness. With the rapidity of social change, persons living a normal life span are required to modify their expectations and behaviour on many occasions if they are to adapt successfully to shifting social conditions. Transformations in technology, sexuality, fertility, family and work life, household structure and many other aspects of life also make it inevitable that different age cohorts will have diverse life experiences and thus, different experiences of health and illness. Epidemiological studies indicate that ageing is not associated with greater risk of experiencing a mental disorder. Moreover, among community residents, the lifetime prevalence of disorders such as depression appears to be lower among older persons compared to their younger counterparts2 . This finding may be due to methodological difficulties inherent in asking persons to recall their first onset of disorder, the omission of elders living in institutional settings from these studies, age differences in willingness to acknowledge feelings, or the fact that persons with mental disorder die earlier than those without such disorders. Given recall and selective reporting problems, the reliability and validity of lifetime estimates of mental illness can be seriously questioned. But the finding may also in part be suggestive of an important cohort difference; younger cohorts may be at greater risk of some mental disorders such as depression2 . If these findings are supported by further evidence, and these conditions
are not self-limited, we might expect that as younger cohorts age, the prevalence and societal burden of mental illness among older persons may increase. The discussion that follows focuses more on severe mental illness than on levels of psychological distress or emotional well-being. The distinction between major mental illness and emotional distress is not always clear. The boundaries between what constitutes elevated symptoms of distress and what constitutes clinical disorder are porous and do not always reflect clinical reality. While the risk of experiencing a clinical disorder may not increase with ageing, there is evidence that depressive symptoms or psychological distress do increase in older age3 . Mirowsky and Ross suggest the approximation of a U-shaped pattern with high depressed mood in late adolescence and young adulthood, lower levels in the middle years, and highest levels at old age4 . Many studies deal with symptoms that do not reach the threshold of disorder but such symptoms can still have devastating effects on functioning and quality of life, and are a major source of disability, surpassing in impact many serious chronic diseases5 . Overwhelmingly, research indicates that mental illnesses are neither randomly distributed nor solely the result of one’s genetic heritage. But, investigating the social causes of mental illness is not inconsistent with the potential causal role of biology or genetics. Severe mental illnesses such as major depression, bipolar conditions and schizophrenia result from complex, but poorly understood, interactions between biological vulnerabilities and psychological and social influences. Adverse social and developmental factors may increase susceptibility to serious mental illness, or may trigger illness among vulnerable persons. There is increasing interest in gene–environment interactions and the role of early abuse and stress interacting with genetic vulnerabilities6 . There is a large body of research documenting that social characteristics and position are associated with the prevalence and incidence of mental disorder. Generally, the research indicates being female, unmarried or from a disadvantaged social class increases risk for experiencing mental health problems. Much debate continues on the relative role of social selection and social causation in influencing these patterns. While the impact of these factors among the elderly has been less well studied, it appears that similar patterns characterize later life7 . Explanations for the social patterning of mental disorder have explored both social causation and social selection. The search for the
Principles and Practice of Geriatric Psychiatry, 3rd edn. Edited by Mohammed T. Abou-Saleh, Cornelius Katona and Anand Kumar 2011 John Wiley & Sons, Ltd
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social causes or contributors to these disorders has been dominated by the stress paradigm that largely focuses on depressive symptoms. Childhood abuse, stressful events and chronic strains, poor coping resources, lack of intimate and instrumental relations and low selfefficacy have all been found to be associated with the occurrence of depressive symptoms and to a lesser extent major depression. Experiences very early in life such as death of a parent, and physical or sexual abuse during childhood may be related to onset of depressive disorders well into adulthood8 . Prenatal and nutritional deficiencies may play a role in neurodevelopmental processes and possibly conditions such as schizophrenia9,10 . Research among the elderly supports the significance of the stress process for understanding the occurrence of depressive disorders in later life7 . Research has also emphasized the importance of social support, both as a buffer to life stress and its absence directly contributing to the onset of depressive symptoms or disorder. However, social support remains a vague concept, having varying operational definitions ranging from marital status, network size and instrumental support, to the subjective qualities of relationships such as intimacy11 . While not conclusive, the research suggests that lack of emotional support is most strongly associated with risk of major depression and most strongly buffers the potential deleterious effects of life stress12 . Contrary to popular impressions, research indicates that individuals are able to maintain supportive relationships as they age; emotional support appears relatively stable across old age, while instrumental support appears to increase13 . However, as people reach old age, lifetime networks become depleted as friends and intimates die. Support when significantly diminished may increase vulnerability to mental distress. There is growing attention to the role of religion or spirituality as causally related to health outcomes, including mental disorder14,15 . Results from many studies indicate that persons who are more involved in religious activities such as going to church report less psychological distress and lower rates of depressive disorder than those who are not involved in such activities15 . Religion may be particularly important for the elderly and for specific cultural groups such as African Americans16 . The pathways through which religiosity affects mental health remain unclear. One plausible hypothesis is that the emotional support and instrumental assistance that might result from religious involvement contribute directly to better health as well as help one cope with the difficulties of life. Research in this area continues to confront difficult selection bias, in that persons in better health may be more able and inclined toward religious participation and that persons drawn to various religious practices may be different in their personalities, attitudes and behaviours than those with lesser or no participation17,18 . While it remains difficult to control for selection effects when trying to untangle the causal roles of social factors, it seems clear that social causation more powerfully explains social patterns of less severe disorders such as depression and is less significant in explaining psychotic disorders such as schizophrenia19 . Understanding the importance of social selection requires taking a life course perspective that highlights the importance of social or health experiences for understanding the occurrence and consequences of mental disorder among the elderly. People bring into later life all the experiences related to family, friends, stressful life events and strains, employment and socioeconomic status that they have accumulated over their lives. All of these experiences influence how we are sorted or selected into various circumstances as we age. The early onset of mental disorder is one such experience. Having a severe mental disorder early in life increases the likelihood of remaining unmarried, especially for men, and increases the risk
of divorce and separation among those who do marry20 . Thus many people with severe mental illness will enter their later years without the benefits of a partner to provide emotional and instrumental support. Early onset also shapes later opportunities for education, employment and earnings21,22 . Even if symptoms remit later in life, it is difficult to overcome these early experiences, and persons with early onset of mental disorder are more likely to find themselves living with significant economic disadvantages in later life. Selection effects are particularly important for understanding the social correlates of severe and persistent disorders such as schizophrenia. Scant research suggests that social factors cause schizophrenia, although early work in the area found that stress acts as a trigger affecting the occurrence and timing of episodes23 . A significant body of work on ‘expressed emotion’ indicates how modification of interactions can prevent and/or reduce episodes24 . Experiences subsequent to the onset of schizophrenia importantly shape one’s life course. The weight of the evidence supports the view that the impairment associated with schizophrenia prevents upward mobility comparable to one’s age cohort and loss of social position because of difficulties completing one’s education and maintaining employment19,25 . Older persons with schizophrenia often carry these deficits they acquired when they were younger. It is clear that those persons who had their first onset of major mental illness early in life bring into their later years life histories likely to be characterized by significant periods of disorder and disruption. But, they also may bring an array of skills and coping strategies, acquired through dealing with illness over many years, and such adaptive skills may help mitigate the potential negative impact of illness during later life. Research indicates, for example, that having a sense of meaning in life, especially a sense of purpose, buffers the effects of traumatic events early in life on symptoms of depression in old age26 . For the majority of older people who have a mental health disorder, it will be a recurrence or continuation of a condition that first occurred much earlier in life. By some estimates, 95% of all cases of major depression have first onset before age 652 . For the majority of persons with depression, age of onset is early in life and seems to be causally related to social factors such as socioeconomic status, exposure to stressful life events and chronic strains, limited coping resources, and deficient social support. Re-occurrence of depression when one is older is commonly associated with similar social factors. In contrast, for the minority of persons who experience first onset of depression in later life, health status may play a larger role. Some research suggests that first-onset of depression in later life is more driven by the experience of health problems than psychosocial circumstances27 . Similar findings have been observed for first onset of bipolar disorder in later life28 . Like depression, most persons with psychotic disorders such as schizophrenia have onset early in life. The prevalence and aetiology of late-onset psychoses remain unclear, although there is a growing literature devoted to the topic. It has been suggested that there may be two types of late-onset psychoses: schizophrenia that occurs first after the age of 40, and schizophrenia-like psychotic disorder that first occurs after the age of 6029 . Both types of disorders are rare and few social factors seem to be associated with risk. One notable exception is gender; the bulk of research suggests that women are at greater risk for late-onset schizophrenia29 , although the reasons for this increased risk are not well understood. It is also clear that social factors matter a great deal for understanding responses to symptoms of mental illness, treatment patterns and
NORMAL AND ABNORMAL AGEING outcomes. Processes of help-seeking are influenced by broad social beliefs about the nature and what should be treated, characteristics of the individual and the social context in which mental illness occurs, and the organization of services and their physical, social and economic accessibility1 . Members of varying age cohorts have been socialized differently in relation to the recognition of symptoms, appropriate sources of help and social stigma of seeking help from particular types of providers. Selection from the community to varying types of service providers is a two-stage process, which depends on general factors affecting the inclination to seek assistance, and other factors more specific to choice among alternative practitioners. Recent evidence suggests that older persons with a mental disorder are less likely to receive care than their younger counterparts30 and are more likely to seek care in the general medical care sector than in the specialty mental health sector. Treatment for mental disorders in older age is shaped by other social factors. Women are more likely to receive care than are men31 . Economic disadvantage is also a substantial barrier to access to health services and prescription medications in settings without adequate health insurance coverage32 . While treatment of depression among older persons has increased dramatically in recent years, there remain significant ethnic and socioeconomic status disparities33 . Differences in patterns of treatment may reflect variation in help seeking behaviours and differences in response to symptoms by health professionals. Older persons with mental disorder are less likely than their younger counterparts with the same disorder to perceive a need for mental health care34 . Many may normalize the symptoms of depression as part of normal ageing35 or perceive such symptoms as less important compared to competing physical and social problems36 . Interpreting symptoms as indicative of mental illness is also complicated by common use of drugs to treat physical illnesses during this stage of life. Prescription and non-prescription drug use is high in elderly populations because of the prevalence of physical illnesses and dementia. The inappropriate use of pharmaceuticals among elderly persons is also common and includes physicians overprescribing to older patients, self-medication and drug interactions37 . Drug sensitivity changes with age-related changes in individuals’ capacity to absorb and metabolize drugs; therefore dosages effective in young patients may be ineffective or excessively high for older patients. Antipsychotics are commonly used ‘off-label’ to treat older persons with dementia, but there is current controversy about such treatment practices because they appear to increase risk of mortality38 . Social factors such as socioeconomic status put persons with mental illness at risk for a number of negative outcomes not directly associated with the illness. Inadequate housing or homelessness remain significant problems for persons with mental illnesses and compromise efforts to provide meaningful services, yet we know little about these issues in older populations39 . Ageing brings more positive outcomes for persons with schizophrenia than might be expected based on research focused on younger persons and clinical samples who remain in treatment for long periods. Research indicates that with ageing, the positive symptoms of schizophrenia abate or remain in remission for longer periods, and that for a significant minority of persons complete remission is possible40 . Longitudinal studies of persons with schizophrenia observe much heterogeneity in its long-term course, with many patients having long remissions, late course improvements and complete remissions41,42 . Most make adequate adjustments to living in the community although social isolation and
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limited quality of life are common1,43 . The impact of family on the course of schizophrenia has received the most research attention, although this research is focused on younger persons. This research suggests that a highly involved critical orientation contributes to relapse24 . Other research suggests that maternal warmth and praise is associated with better quality of life outcomes among middle-aged persons with schizophrenia44 . Social policies also influence the types of institutions where elderly people receive care. In the 1950s and 1960s, the organization of services in the United States and many Western nations meant that many persons with mental disorders ended up in psychiatric hospitals and nursing homes, and many elderly persons with mental illnesses had spent much of their lives in such institutions. In the United States large scale deinstitutionalization was only possible with the expansion of welfare programmes that provided subsistence and payment for alternative residential care for mentally ill patients in the community. Current cohorts of elderly persons with major mental illnesses confront a much different landscape of services than their predecessors. Among those seeking help, most will be seen in primary care, not specialty mental health care34 . Assessing depression within the constellation of physical concomitants that might be attributed to a variety of other conditions poses diagnostic challenges to the general physician. It is not surprising, therefore, that depression among older persons often goes undiagnosed45 . This problem may be even more pronounced for African American patients46 . There has been much recent effort to integrate mental health services into primary medical care. Large-scale multifaceted interventions bringing mental health care into primary care settings have been found to be effective in reducing symptoms and improving quality of life for persons with depression, while also being cost effective. These interventions are intensive, typically including enhanced screening to improve the identification of cases of depression, patient and provider education, case managers responsible for tracking patient outcomes and adherence to treatment, and the availability of a psychiatrist for consultations. However, even at their best, these interventions show how difficult it is address the needs of the elderly with depression. In the most widely replicated model, IMPACT, for example, only about one quarter of patients in the intervention (compared to less than 10% in usual care) achieved remission at 12 months47 . While most of the research on how social factors impact the occurrence of mental illness or the response to symptoms of mental illness is based on community samples, nursing homes remain the social environment where many elderly persons find themselves. In some sense, the traditional nursing home echoes the conditions of the long term psychiatric hospitals that characterized care for the mentally ill in the past. Typically admissions to nursing homes occur when individuals are incapable of caring for themselves, when their physical and psychiatric problems create unmanageable burdens for their caretakers, or when community caretakers are no longer available. Admission is often triggered by such events as a loss of function following trauma, such as hip fractures, confusion and wandering, and incontinence. Traditional nursing homes, like the traditional longterm mental hospital, contribute to an institutional syndrome resulting from vulnerabilities of patients as they respond to decreased social participation, sensory deprivation, loss of efficacy and control over daily life decisions, institutionalization, routinization and the like. There is persuasive evidence that efforts to keep patients involved
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and participating in valued activities help for both mental and physical function. Many nursing homes fail to give these social aspects of life adequate attention, and patients spend much of their time in isolation and uninvolved. Moreover, historically, there has been evidence that psychotropic drugs were being over-prescribed in nursing homes to control patients and ease staff workloads. Recent evidence suggests that these practices have been reduced as the result of legislation in the late 1980s in the United States48 . Nursing care may be the best treatment context for some patients who are seriously incapacitated and require a broad range of services difficult to provide in the home or in other community settings, but most impaired elderly benefit from settings that are more successful in sustaining self-efficacy and social engagement. Recent developments in the nursing home industry suggest that such settings are possible; for example, the Green House model emphasizes small residential (family-like) housing, privacy, independence and control over activities of daily life as much as clinical status allows49 . Early results indicate that functioning and quality of life, including emotional well-being, are more positive for individuals in such types of homes compared to traditional nursing home settings50 . Demographic shifts mean that the social patterning of mental illness in later life and our responses to it may be very different with future cohorts of older persons than what we see today. The United States and many other nations are facing an ageing population, with the number of older persons with mental illness more prevalent. The capacity for any society to cope with mental illness depends on the organization of kinship groups and households, and the existing social institutions in a society. The growing prevalence of divorce, single-person households, small families, high female participation in the workforce, geographic mobility and other trends make it difficult to put increasing reliance on informal social networks for caretaking. Developing alternative structures that are financially viable and humane constitutes a growing challenge.
REFERENCES 1. Mechanic D. Mental Health and Social Policy: Beyond Managed Care, 5th edn. Boston, MA: Allyn & Bacon, 2008. 2. Kessler RC, Berglund P, Demler O et al. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2005; 62: 593–602. 3. Mirowsky J, Ross CE. Age and depression. J Health Soc Behav 1992; 33: 187–205. 4. Mirowsky J, Ross CE. Well-being across the life course. In Horwitz AV, Scheid TL (eds), A Handbook for the Study of Mental Health: Social Contexts, Theories, and Systems. Cambridge: Cambridge University Press, 1999, 328–47. 5. Wells KB, Sturm R, Sherbourne CD, Meredith LS. Caring for Depression. Cambridge, MA: Harvard University Press, 1996. 6. Brown GW, Harris TO. Depression and the serotonin transporter 5-HTTLPR polymorphism: a review and a hypothesis concerning gene–environment interaction. J Affect Disord 2008; 111: 1–12. 7. Cairney J, Krause N. The social distribution of psychological distress and depression in older adults. J Aging Health 2005; 17: 807–35. 8. Kessler RC, Davis CG, Kendler KS. Childhood adversity and adult psychiatric disorder in the US National Comorbidity Survey. Psychol Med 1997; 27: 1101–19.
9. St Clair D, Xu M, Wang P et al. Rates of adult schizophrenia following prenatal exposure to the Chinese famine of 1959–61. JAMA 2005; 294: 557–62. 10. Susser E, Hoek HW, Brown A. Neurodevelopmental disorders after prenatal famine: the story of the Dutch famine study. Am J Epidemiol 1998; 147: 213–16. 11. Thoits PA. Conceptual, methodological and theoretical problems in studying social support as a buffer against life stress. J Health Soc Behav 1982; 23: 145–59. 12. Blazer DG, Hybels CF. Origins of depression in later life. Psychol Med 2005; 35: 1241–52. 13. Shaw BA, Krause N, Liang J, Bennett J. Tracking changes in social relations throughout late life. J Gerontol B Psychol Sci Soc Sci 2007; 62: S90–99. 14. Idler EL, Kasl SV. Religion among disabled and non-disabled persons II: Attendance at religious services as a predictor of the course of disability. J Gerontol B Psychol Sci Soc Sci 1997; 52: S306–16. 15. Moreira-Almeida A, Neto FL, Koenig HG. Religiousness and mental health: a review. Rev Bras Psiquiatr 2006; 28: 242–50. 16. Chatters LM, Bullard KM, Taylor RJ et al. Religious participation and DSM-IV disorders among older African Americans: findings from the National Survey of American Life. Am J Geriatr Psychiatry 2008; 16: 957–65. 17. Idler EL. Religion and aging. In Binstock RH, George LK (eds), Handbook of Aging and the Social Sciences, 6th edn. San Diego, CA: Elsevier, 2006, 277–300. 18. Idler EL. Health and religion. In Cockerham W (ed.), The New Blackwell Companion to Medical Sociology. Oxford: Blackwell, 2010, 133–158. 19. Dohrenwend BP, Levav I, Shrout PE et al. Socioeconomic status and psychiatric disorders: the causation–selection issue. Science 1992; 255: 946–52. 20. Kessler RC, Walters EE, Forthofer MS. The social consequences of psychiatric disorders, III: Probability of marital stability. Am J Psychiatry 1998; 155: 1092–6. 21. Breslau J, Lane M, Sampson N et al. Mental disorders and subsequent educational attainment in a US national sample. J Psychiatr Res 2008; 42: 708–16. 22. Kessler RC, Heeringa S, Lakoma MD et al. Individual and societal effects of mental disorders on earnings in the United States: results from the National Comorbidity Survey Replication. Am J Psychiatry 2008; 165: 703–11. 23. Brown GW, Birley JL. Crises and life changes and the onset of schizophrenia. J Health Soc Behav 1968; 9: 203–14. 24. Leff J, Vaughn C. Expressed Emotion in Families. New York: Guilford, 1985. 25. Mechanic D. Medical Sociology, 2nd edn. New York: Free Press, 1978. 26. Krause N. Evaluating the stress-buffering function of meaning in life among older people. J Aging Health 2007; 19: 792–812. 27. Sneed JR, Kasen S, Cohen P. Early-life risk factors for late-onset depression. Int J Geriatr Psychiatry 2007; 22: 663–7. 28. Hays JC, Krishnan KR, George LK et al. Age of first onset of bipolar disorder: demographic, family history, and psychosocial correlates. Depress Anxiety 1998; 7: 76–82. 29. Howard R, Rabins PV, Seeman MV et al. Late-onset schizophrenia and very-late-onset schizophrenia-like psychosis: an international consensus. Am J Psychiatry 2000; 157: 172–8. 30. Wang PS, Lane M, Olfson M et al. Twelve-month use of mental health services in the United States: results from the National
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Comorbidity Survey Replication. Arch Gen Psychiatry 2005; 62: 629–40. Ojeda VD, McGuire TG. Gender and racial/ethnic differences in use of outpatient mental health and substance use services by depressed adults. Psychiatr Q 2006; 77: 211–22. Berk ML, Schur CL, Cantor JC. Ability to obtain health care: recent estimates from the Robert Wood Johnson Foundation National Access to Care Survey. Health Affairs 1995; 14: 139–46. Crystal S, Sambamoorthi U, Walkup JT et al. Diagnosis and treatment of depression in the elderly Medicare population: predictors, disparities, and trends. J Am Geriatr Soc 2003; 51: 1718–28. Klap R, Unroe K, Un¨utzer J. Caring for mental illness in the United States: a focus on older adults. Am J Geriatr Psychiatry 2003; 11: 517–24. Sarkisian CA, Lee-Henderson MH, Mangione CM. Do depressed older adults who attribute depression to ‘old age’ believe it is important to seek care? J Gen Intern Med 2003; 18: 1001–5. Proctor EK, Hasche L, Morrow-Howell N et al. Perceptions about competing psychosocial problems and treatment priorities among older adults with depression. Psychiatr Serv 2008; 59: 670–75. Lipton HL, Lee PR. Drugs and the Elderly: Clinical, Social, and Policy Perspectives. Stanford, CA: Stanford University Press, 1988. Jeste DV, Blazer D, Casey D et al. ACNP White Paper: update on use of antipsychotic drugs in elderly persons with dementia. Neuropsychopharmacology 2008; 33: 957–70. Cohen CI. Aging and homelessness. Gerontologist 1999; 39: 5–14. Cohen CI (ed.). Schizophrenia into Later Life: Treatment, Research and Policy. Arlington, VA: American Psychiatric Publishing, 2003.
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41. Davidson L, McGlashan TH. The varied outcomes of schizophrenia. Can J Psychiatry 1997; 42: 34–43. 42. Harding CM, Zubin J, Strauss JS. Chronicity in schizophrenia: fact, partial fact, or artifact? Hosp Community Psychiatry 1987; 38: 477–86. 43. Mechanic D. Organization of care and quality of life of persons with serious and persistent mental illness. In Katschnig H, Freeman H, Sartorius N (eds.), Quality of Life in Mental Disorders, 2nd edn. New York: Wiley Interscience, 2006, 309–19. 44. Greenberg JS, Knudsen KJ, Aschbrenner KA. Prosocial family processes and the quality of life of persons with schizophrenia. Psychiatr Serv 2006; 57: 1771–7. 45. Un¨utzer J. Clinical practice. Late-life depression. N Eng J Med 2007; 357: 2269–76. 46. Gallo JJ, Bogner HR, Morales KH et al. Patient ethnicity and the identification and active management of depression in late life. Arch Intern Med 2005; 165: 1962–8. 47. Hunkeler EM, Katon W, Tang L et al. Long term outcomes from the IMPACT randomised trial for depressed elderly patients in primary care. Br Med J 2006; 332: 259–63. 48. Hughes CM, Lapane KL. Administrative initiatives for reducing inappropriate prescribing of psychotropic drugs in nursing homes: how successful have they been? Drugs Aging 2005; 22: 339–51. 49. Rabig J, Thomas W, Kane RA et al. Radical redesign of nursing homes: applying the green house concept in Tupelo, Mississippi. Gerontologist 2006; 46: 533–9. 50. Kane RA, Lum TY, Cutler LJ et al. Resident outcomes in smallhouse nursing homes: a longitudinal evaluation of the initial green house program. J Am Geriatr Soc 2007; 55: 832–9.
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Part C
Diagnosis and Assessment
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Classification of Dementia and other Cognitive Disorders in ICD-10 and DSM-IV A. Jablensky and J.E. Cooper Department of Psychiatry and Behavioural Science, Medical Research Foundation Building, Perth, Australia
The classification of mental disorders in the Tenth Revision of the International Classification of Diseases (ICD-10) includes a revised content that reflects the most important advances in research and clinical practice at the time of its conception. It is presented in different versions for different types of professional users. The differences are, however, in degrees of detail, and the versions are compatible with each other since they are all derived from the same basic document, the ‘Clinical Descriptions and Diagnostic Guidelines’1 .
THE USES OF ICD-10 ICD-10 has necessarily retained its historical purpose of facilitating the recording of national and international statistics of morbidity and mortality, but has the added values of also being designed as a uniquely international aide to clinical work, teaching, and research. It achieves these objectives by means of an updated list of diagnostic rubrics, a set of glossary-type definitions of disorders, and additional explicit diagnostic criteria. The latter have been developed in two versions: (a) clinical diagnostic guidelines for routine use, allowing sufficient flexibility and discretion in the application of “clinical judgement” in the hospital ward or the out-patient clinic; and (b) diagnostic criteria for research (ICD-10-DCR) providing stringent decision-making rules to increase the specificity of diagnostic classification and thus ensure a high level of sample homogeneity for the purposes of clinical, biological and other research2 . As a result of a great deal of collaboration between the advisers to the World Health Organisation and the several Task Forces that assembled DSM-IV on behalf of the American Psychiatric Association during the last few years of the preparation of both the classifications, there are very few important differences between them. Since the same body of internationally published research experience and literature was available to both sets of experts during the processes of development, those differences that remain are mainly differences of opinion rather than of fact. Some differences reflect the need for ICD-10 to accommodate a much broader base of international experience and opinions than a national classification. In the development of ICD-10, experts from many different cultures and languages were involved from the earliest stages. As in ICD-9, Chapter V deals with “Mental and Behavioural Disorders”, and is intended for the recording of the clinical syndromes
as presented and experienced by the patient. If a specific underlying cause of the disorder is known (or highly probable), additional codes should also be used from other chapters of ICD-10, such as Chapter I; Infectious and parasitic diseases, Chapter II; Neoplasms, or Chapter VI; Diseases of the Nervous System.
DEMENTIA IN ICD-10 In ICD-10, the dementias are embedded in the section on organic and symptomatic mental disorders (codes F00-F09) which contains the following major rubrics:
• • • • • • • • •
Dementia in Alzheimer’s disease. Vascular dementia. Dementia in diseases classified elsewhere. Unspecified dementia. Organic amnestic syndrome, other than induced by alcohol and drugs. Delirium, other than induced by alcohol and drugs. Other mental disorders due to brain damage and dysfunction and to physical disease. Personality and behavioural disorders due to brain disease, damage and dysfunction Unspecified organic or symptomatic mental disorder.
In contrast to ICD-9, the distinction between psychotic and non-psychotic illnesses is of no taxonomic consequence in ICD-10, where disorders of different psychopathological expression are grouped together on the basis of established or presumed common aetiology. In the particular instance of section F0, in which the dementing disorders are included, the underlying classificatory characteristic of “organic” is defined in the sense that “the syndrome so classified can be attributed to an independently diagnosable cerebral or systemic disease or disorder”. The subsidiary term “symptomatic” is not used in the titles of individual disorders but it is included in the overall title of the block F00 – F09. This is because it is widely used in many countries to indicate those organic mental disorders in which cerebral involvement is secondary to a systemic extra-cerebral disease or disorder. In other words, ‘symptomatic’ in this context is a subdivision of the wider term ‘organic’.
Principles and Practice of Geriatric Psychiatry, 3rd edn. Edited by Mohammed T. Abou-Saleh, Cornelius Katona and Anand Kumar 2011 John Wiley & Sons, Ltd
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Another feature of ICD-10, as compared to earlier classifications, is the omission of any reference to age as a defining criterion of the disorders accompanied by a cognitive deficit. The terms “senile” and “presenile” are practically absent in the classification, and there is no provision for identifying any mental disorder as necessarily a result of aging. The classification does, however, allow the recording of an unusually early or late onset of the disorder. In other words, the mental disorders occurring in the elderly are no longer considered to belong in a separate category of morbidity. This is very much in line with research conducted in the past three decades which has demonstrated that the relatively high prevalence of mental morbidity in the elderly in Western cultures is related to a wide range of psychosocial factors (e.g. social isolation, cultural uprooting and institutionalization), as well as to physical co- morbidity, but that the aging process itself does not produce nosologically specific forms of disorders. If section F0 of ICD-10 is used as a diagnostic decision tree, there is a choice of five entry points at the level of clinical syndrome: (i) dementia; (ii) amnesic syndrome; (iii) delirium; (iv) organic quasifunctional disorder (affective, delusional, hallucinatory or other); and (v) personality or behavioural disorder. Once a disorder is identified at this general syndrome level, the next step is defined by the diagnostic guidelines which lead into more specific diagnostic categories. The diagnostic decision rules for dementia illustrate the point. The syndrome of dementia is defined in ICD-10 by “evidence of a decline in both memory and thinking, which is of a degree sufficient to impair functioning in daily living”, in a setting of clear consciousness. For a confident diagnosis to be established, such disturbances should have been present for at least 6 months. Deterioration of emotional control, social behaviour and motivation represent significant additional features but the overriding criterion is the presence of memory, learning and reasoning decline. The ICD-10 DCR (research criteria) add anchor points for a grading of the deficits into mild, moderate and severe, separately for memory and intellectual capacity. The overall grading of the severity of dementia is made on the basis of the function which is more severely impaired. Once the presence of the syndrome of dementia is established, the diagnostic process branches off into the different clinical varieties of dementia typical of Alzheimer’s disease, vascular dementia, and dementia in diseases classified elsewhere (including Pick’s disease, Creutzfeldt-Jakob disease, Huntington’s disease, Parkinson’s disease, HIV disease, and a range of systemic and infectious diseases such as hepatolenticular degeneration, lupus erythematosus, trypanosomiasis, and general paresis). Dementia in Alzheimer’s disease is subdivided into Type I (onset after the age of 65) and Type 2 (onset before the age of 65). Although the ICD-10-DCR criteria emphasize the ultimate criterion of the neuropathological examination and the supporting role of brain imaging, they nevertheless allow for a confident clinical diagnosis to be made, if clear evidence of a memory and intellectual performance deterioration has been present for 6 months or more. The ICD-10 criteria for vascular dementia are broader than the corresponding DSM-IV criteria: they include not only multi-infarct (predominantly cortical) vascular dementia, but also the subcortical dementias (Binswanger’s encephalopathy being an example), as well as the mixed cortical and subcortical forms. As regards the diagnosis of delirium, ICD-10 has abandoned the distinction between acute and subacute deliria; the condition is defined as “a unitary syndrome of variable duration and degree of severity ranging from mild to very grave”, with an upper limit of 6 months’ duration and a subdivision into delirium superimposed on dementia and delirium not superimposed on dementia.
The rubric “other mental disorders due to brain damage and dysfunction and to physical disease” includes disorders with “functional” characteristics (e.g. hallucinosis, catatonia, schizophrenia-like disorder, and mood disorders) which arise in the context of demonstrable organic illness, such as cerebral disease, systemic disorders, and brain dysfunction associated with toxic disorders (other than due to alcohol or drugs). An important, not yet fully validated, addition to this rubric is the “mild cognitive disorder” attributable to physical co-morbidity which is defined as transient but nevertheless involving memory and learning difficulties. However, the requirement that “this diagnosis should be made only in association with a specified ohysical disorder” is in need of revision, since in a proportion of cases this diagnosis may reflect the early, pre-dementia stage of Alzheimer’s disease. Finally, personality and behavioural disorders due to brain disease, damage and dysfunction include familiar conditions such as organic personality disorder (the frontal lobe syndrome but also other lesions to circumscribed areas of the brain), postencephalitic syndrome, postconcussional syndrome, and some new entities, e.g. right hemispheric organic affective disorder (altered ability to express and comprehend emotion without true depression). In conclusion, two features of ICD-10 should be emphasized. First, as already noted, it does not identify the mental disorders in the elderly as a separate or special category of psychiatric morbidity. In addition to the F0 section listing the organic and symptomatic mental disorders, psychiatric disturbances arising in the elderly population can be classified, according to their presentation and course, in any of the other major sections of ICD-10 (except for F8 and F9, which deal with developmental disorders and behavioural and emotional disorders occurring in childhood and adolescence). Second, although ICD-10 is not explicitly a multiaxial classification, there are two ways in which multi-axial coding can be achieved if required. The simplest way is to use extra codes from the other chapters of ICD-10 in addition to those in Chapter V; any physical disorders present can be recorded by codes form Chapters I to XIX, and codes from the final two chapters can be used to cover other noteworthy aspects of the clinical picture. These are Chapter XX; External Causes of Morbidity and Mortality (the X and Y codes, covering drugs causing adverse effects in therapeutic use, and injuries and poisoning), and Chapter XXI; Factors Influencing Health Status and Contact With Health Services (the Z codes, which include a variety of social, family and life-style factors). Another and more comprehensive option is to use the special Multi-axial System now available, which was developed by means of an international collaborative study organised by WHO Geneva3 . This provides three descriptive axes: Axis 1 – Clinical Diagnosis, Axis II – Disablements, and Axis III – Contextual Factors. These Axes are a convenient re-arrangement of the chapters of ICD-10 listed above, with the addition of a brief set of ratings covering physical disabilities.
DEMENTIA AND OTHER COGNITIVE DISORDERS IN DSM-IV In DSM-IV (and its revised version DSM-IV TR) dementias and other mental disorders associated with brain disease are grouped into a section entitled “Delirium, dementia, and amnestic and other cognitive disorders”. In contrast to ICD-10 and the earlier DSM-IIIR, the term “organic” mental disorders is no longer used in DSM-IV, to avoid the implication that “nonorganic” mental disorders do not
DIAGNOSIS AND ASSESSMENT have a biological basis14 . While ICD-10 retains a general description of dementia as a syndrome occurring in Alzheimer’s disease, cerebrovascular disease and “other conditions primarily or secondarily affecting the brain”, the DSM-IV classification lists dementias as specific disorders which “share a common symptom presentation but are differentiated based on etiology”. Specific diagnostic criteria are provided for dementia of the Alzheimer’s type, vascular dementia, and dementia due to other medical conditions (HIV disease, head trauma, Parkinson’s disease, Huntington’s disease, Pick’s disease and Creutzfeldt-Jakob disease). A separate DSM-IV category, which has no counterpart in ICD-10, is substance-induced persisting dementia, defined as significant cognitive impairment persisting long after the symptoms of substance intoxication or withdrawal have abated. Another difference from ICD-10 involves the category of “dementia due to multiple etiologies”, introduced to cover “the common situation in which the dementia has more than one etiology”, such as a condition arising as a result of Parkinson’s disease with co-occurring long-term substance use. Finally, the DSM-IV section contains residual categories for “dementia not otherwise specified” and “cognitive disorder not otherwise specified”, to enable the coding of dementing illnesses or other cognitive dysfunction that do not meet the criteria for any of the specific types, or for which no specific etiology has yet been established. While the DSM-IV diagnostic criteria and the ICD-10 diagnostic guidelines for delirium essentially agree, there are differences between the two classifications regarding the specific rubrics and their composition. Thus, the ICD-10 heading for the group of delirious disorders is “delirium, not induced by alcohol and other psychoactive substances”, with separate coding provisions for delirium not superimposed on dementia, delirium superimposed on dementia, other delirium and delirium unspecified (alcohol or substance use induced delirium is coded in the ICD10 section “Disorders due to psychoactive substance use”). In DSM-IV, both “delirium due to a general medical condition” and substance-induced delirium are coded within the same section, along with “delirium due to multiple etiologies” and “delirium not otherwise specified”. Another difference between ICD-10 and DSM-IV concerns the placement of psychiatric syndromes and personality or behavioural disorders associated with cerebral disease. The ICD-10 section “Delirium, dementia, and amnestic and other cognitive disorders” provides a fairly detailed classification of “organic” hallucinosis, catatonic disorder, delusional disorder, mood and anxiety disorders, personality disorders and specific syndromes, such as postconcussional and postencephalitic syndrome. Notably, the same section contains the category “mild cognitive disorder” and provides diagnostic guidelines for this rubric, while acknowledging that “the boundaries of this category are still to be firmly established”. In DSM-IV, “mild neurocognitive disorder” is an inclusion term under “cognitive disorder not otherwise specified”, with diagnostic criteria contained in Appendix B “for further study”. Both ICD-10 and DSM-IV have proved to be essential tools for clinicians, epidemiologists, and – perhaps to a lesser degree – for researchers working in the rapidly evolving areas of the neuroscience and genetics of neurocognitive disorders. In a thoughtful commentary and critique of the two classifications, Reisberg13 noted that in several respects the present diagnostic manuals reflect knowledge that is somewhat dated and fail to incorporate recent advances. Thus, the DSM-IV definition of dementia requires “impairment in memory” as a cardinal and necessary criterion, not acknowledging
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that diseases such as vascular dementia and frontotemporal dementia are not characterized by prominent memory impairment, at least in their early stages. The DSM-IV definition mentions disturbance in executive functioning but omits the behavioural and emotional changes, as well as the diminishing capacity to carry out activities of daily living. Importantly, the DSM-IV definition proposes that the diagnosis of Alzheimer’s type dementia can only be made by exclusion, i.e. once other etiologies for the dementia have been ruled out. This is at variance with the current international consensus (including the American Geriatric Society) that Alzheimer’s disease should be amenable to diagnosis by inclusion, rather than exclusion. Another suggested change is the removal, from both DSM and ICD, of the distinction between early onset (before 65 years of age) and late onset (after 65 years) Alzheimer’s disease. Further proposals concern introducing in the future classifications staging procedures for dementia; broadening the definition of Pick’s disease to include frontotemporal dementia; and revising the description of dementia in Parkinson’s disease and Lewy body dementia.
PROSPECTS FOR THE FUTURE It is only a few years before the next edition of the international classification, ICD-11 is ready for use, and there are at present plenty of issues worthy of debate. Both terminological and conceptual issues related to the current ICD-10 classification of this group of conditions have been raised since its introduction in the early 1990s. Thus, the term “organic”, sitting uneasily within the title of the ICD-10 section, has often been singled out for critique as a legacy of a dualist tradition and a schism between brain-based “neurological” diseases and “functional” psychiatric disorders that is no longer tenable4,5 . The non-invasive techniques for brain imaging, such as MRI, SPECT and PET-scans, are demonstrating a variety of structural and functional abnormalities in the brains of some (but by no means all) patients with the familiar clinical syndromes, that are also present in substantial proportions of normal subjects. These changes are ‘organic’ in a general sense of being something physical, but not in the way the term is used in the ICD (that is, to indicate a concurrent and diagnosable physical disorder). It will probably soon be time to abandon ‘organic’ as a term to be used in a classification, and to develop new terms and concepts that will make these more subtle differentiations clear. The term “neurocognitive disorders”, thought to capture both the concepts of cognitive disturbance and of an altered neural substrate, has been proposed in a recent review of the evidence supporting the grouping of the dementias, amnesic syndromes and deliria into a single classificatory “cluster”6 . In addition, a critical examination of the very term “dementia” has also found it wanting for three main reasons7 . First, it is now clear that memory impairment is just one of several cognitive domains that are affected to varying degrees in this group of disorders (other domains include language, attention, executive function, visuospatial ability, speed of information processing and manual dexterity). Secondly, the operational definitions of the diagnostic criteria for dementia in both ICD-10 and DSM-IV are insufficiently specific, leading on occasions to gross discrepancies in the assessment of the prevalence of dementia in population studies8,9 . Thirdly, in its categorical usage the term is stigmatizing and has connotations of extreme disability and dependence that tend to arouse severe anxiety in patients and family members. As a possible remedy, terms like “vascular cognitive disorder”, or “cognitive disorder in Alzheimer’s disease” have been proposed.
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Complex problems with far-reaching conceptual implications for the classification of this group of disorders arise out of recent advances in their study with the tools of molecular genetics, proteomics and biomarker research. While conditions such as Alzheimer’s disease, Huntington’s disease, or Creutzfeldt-Jakob disease have been traditionally regarded as being among the few “true” discrete disease entities within the psychiatric classification, owing to the presence of “hallmark” brain lesions, recent evidence challenges seriously this view10 . Current molecular classifications distinguish between four groups of neurodegenerative diseases: tauopathies (e.g. Alzheimer’s disease, Pick’s disease, frontotemporal dementia, progressive supranuclear palsy); alpha-synucleinopathies (e.g. Parkinson’s disease, dementia with Lewy bodies, multiple system atrophy); neurofilamentopathies (e.g. dementia with neurofilament inclusions); and prion diseases (e.g. Creutzfeldt-Jakob disease, Gerstmann-Str¨aussler-Scheinker syndrome, fatal familial insomnia). There is, however, increasing evidence of marked individual variability within the groups, as well as extensive overlap across the diseases and syndromes in terms of structure, molecular composition and distribution of brain lesions, raising the question of common aetiological and pathogenetic mechanisms11,12 . In the presence of both genetic heterogeneity and clinical pleiotropy, the nosological status of the individual disorders becomes less certain that previously assumed. Generally, two positions have been articulated in the recent literature (Armstrong et al . 2005): (i) the benefits of retaining the concept of distinct nosological entities outweighs its limitations; the latter can be constrained by using the existing diagnostic criteria in conjunction with refined molecular and other biomarker analysis; (ii) the traditional disease entities represent points on a continuum of neuropathological change and a clinical spectrum of syndromes rather than diseases. Whatever form the ICD-11 classification takes, it seems likely that the principle of recording the clinical picture by means of Chapter V and the underlying cerebral or other physical cause by means of other chapters will remain. Research is now providing many, though not entirely consistent, clues about the exact place and the histological and molecular nature of the lesions in the central nervous system that give rise to the clinical syndromes, but the clinical syndromes themselves will not change, and will always need to be reliably recorded.
REFERENCES 1. WHO (1992) The ICD-10 Classification of Mental and Behavioural Disorders. Clinical Descriptions and Diagnostic Guidelines. World Health Organization. Geneva
2. WHO (1993) The ICD-10 Classification of Mental and Behavioural Disorders. Diagnostic Criteria for Research. World Health Organization. Geneva. 3. WHO (1997) Multi-axial Presentation of ICD-10 for Use in Adult Psychiatry. Cambridge: Cambridge University Press. 4. Spitzer RL, First MB, Williams JBW et al . (1992) Now is the time to retire the term “organic mental disorders”. American Journal of Psychiatry 149, 240–244. 5. Sachdev P. (1996) A critique of ‘organic’ and its proposed alternatives. Australian and New Zealand Journal of Psychiatry 30, 165–170. 6. Sachdev P, Andrews G, Hobbs MJ et al . (2009) Neurocognitive disorders: Cluster 1 of the proposed meta-structure for DSM-V and ICD-11. Psychological Medicine (in press). 7. Sachdev P. (2000) Is it time to retire the term “dementia”? Journal of Neuropsychiatry and Clinical Neuroscience 12, 276–279. 8. Wetterling T, Kaniz R-D, Borgis K-J. (1996) Comparison of different criteria for vascular dementia (ADDTC, DSM-IV, ICD10, NINDS-AIREN). Stroke 27, 30–36. 9. Erkinjuntti T, Ostbye T, Steenhuis R et al. (1997) The effect of differential diagnostic criteria on the prevalence of dementia. New England Journal of Medicine 337, 1667–1674. 10. Armstrong RA. (2005) Overlap between neurodegenerative disorders. Neuropathology 25, 111–124. 11. Perl DP, Olanow CW, Calne D. (1998) Alzheimer’s disease and Parkinson’s disease: distinct entities or extremes of a spectrum of neurodegeneration? Annals of Neurology 44, S19–31. 12. Morris JC. (2000) The nosology of dementia. Neurologic Clinics 18, 773–788. 13. Reisberg B (2006) Diagnostic criteria in dementia: A comparison of current criteria, research challenges, and implications for DSM-V. Journal of Geriatric Psychiatry and Neurology 19, 137–146. 14. American Psychiatric Association (1994) Diagbostic and Statistical Menual of Mental Disorders. Fourth Edition. Washington DC.
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Taking a Psychiatric History from Elderly Patients Sunita Sahu and Monica Crugel Oxleas NHS Foundation Trust, Memorial Hospital, Shooters Hill, London, UK
INTRODUCTION When taking a psychiatric history from an elderly person, the general guidance on establishing rapport and taking a medical and psychiatric history apply, but there are also a few particularities. The great heterogeneity of this population in terms of general health and frailty, cognitive abilities and the need for support requires the approach to be adjusted in each case. Clinicians may often be enquiring about someone’s life lived before ‘their time’ and can use this as an opportunity to allow the patient to feel empowered – after all the clinician might know better than the patient what their general and mental health problems are at the moment but only he/she is an expert in their own life history. Sometimes, a little more encouragement and verbal and non-verbal cues of friendliness, respect and openness than with an younger adult patient are needed for establishing a good rapport and obtaining the information. For fear of wasting your time or bringing irrelevant issues into discussion, your elderly patient might not tell you part of the story. Also, pre-conceptions about ‘normal’ ageing might lead to essential symptoms such as acute or chronic pains, low energy, lack of hope, poor sleep, boredom or lack of social interaction not being mentioned by the patient. Attention to non-verbal cues as well as reassurance that you are interested to hear it all and prompting can help complete the picture.
GETTING READY FOR THE INTERVIEW Before meeting the patient prepare for the interview. Determine the reason for referral and look at the available medical and psychiatric history and current medication. Ask if the patient will be attending alone or accompanied and if special arrangements will be required in the room, for example if the patient is in a wheelchair.
THE INTERVIEW After introducing yourself, make sure the patient and their companion are comfortable and check if the patient can hear and understand you. If not, can communication be improved with hearing aids or writing things down and/or involvement of interpreter or the sensory team?. Apart from sensory problems, cognitive deficits (short attention span, memory problems) and dysphasia can affect communication and prevent relevant information being obtained from the patient. In these cases an informant is essential for proper assessment. Adjust the pace of dialogue to the patient’s needs: too slow
for a cognitively intact patient can sound condescending, too fast for people who cannot keep up can be disastrous. If the patient is accompanied, establish who the companion is and what their role will be during the interview. Are they an informant or will they provide support for the patient? Have they requested the assessment? The first interview with the patient and the psychiatric history obtained in this session is extremely important as future assessments will refer to it. Thus, details on nature and onset of all previous episodes, triggers and prodromes, risk factors, duration of episodes, medical co-morbidities, interventions (medication, hospitalization, sectioning, psychotherapy, home help, etc.) and their effect, pharmacological history including compliance, quality of recovery and level of functioning when recovered, should be recorded whenever possible. Your knowledge in psychopathology should guide the questions into obtaining relevant information. To start the interview, allow the patient or/and informant to explain their view of the presenting complaint. Start with general questions such as ‘Have you ever had any problems to do with your mental health?’ and ‘Have you ever seen your GP or a psychiatrist for these?’, then explore each concern in turn. A patient with poor insight into his previous psychiatric problems might acknowledge having been under psychiatrists for a long time but not having had a mental health problem. Conversely, many people suffer from sub-clinical symptoms or even disorders of clinical severity but have never been assessed or had any treatment.
HISTORY OF THE PRESENTING COMPLAINT The context of symptoms’ onset is of great relevance in geriatric psychiatry. Social and medical factors can play a greater role than genetics in some psychiatric disorders with late onset and, without addressing these, the patient might not recover fully. Consideration of recent losses such as retirement, bereavement, change in social and financial circumstances, social isolation, loss of abilities and increase in dependency etc. must inform therapeutic intervention, thus recording them is important. Medical conditions as well as medications prescribed for these can be associated with psychiatric disorders: stroke1 and cancer2 have a high co-morbidity with depression; organ failure may cause delirium3 ; respiratory problems are frequently associated with anxiety or panic attacks4 ; some antihypertensives can cause depression5 ; cortisone6 and anti-Parkinsonian drugs may cause psychosis; drugs
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with anticholinergic effects can cause or accentuate confusion, to enumerate only some. Conversely, care must be given to falsely perceived onset of symptoms. A classic example is memory problems starting ‘suddenly’ after the spouse’s death; it is often the case that the patient’s memory problems had been more longstanding but not apparent due to spouse’s interventions and prompting. Careful questioning of relatives and other informants would probably reveal cognitive problems prior to bereavement. Sometimes the perceived onset is in fact an aggravation of pre-existing symptoms or the moment at which their intensity becomes significant. An answer such as ‘I have always had this problem’ requires clarification as to why they presented for assessment now. The present disorder might have started in a different form, for example psychosis or confusion following a long depressive episode pointing towards a diagnosis of psychotic depression; confusion following a serious illness, surgery or stroke suggesting delirium; depression with previous episode(s) of mania suggesting bipolar disorder; dementia starting with depression, anxiety or psychosis; substance abuse starting with anxiety or depression. A sudden onset of psychiatric symptoms can suggest organic aetiology. After identifying the presenting complaint, brief questioning about any other problem, be it social, medical or psychiatric, will help complete the picture.
PAST PSYCHIATRIC HISTORY One approach is to start with the personal history and once you have information about the patient’s lifeline and major life events start asking about the psychiatric history. On one hand this reassures the patient that you are assessing them in an holistic way and are not only ‘fishing’ for symptoms and, on the other hand, it gives you a better view of the previous level of functioning and, if applicable, the impact of the psychiatric problem on their lives. Some patients may prefer to go straight to the problem. It is not unheard of for serious lifelong psychiatric illnesses to be diagnosed in old age and a thorough psychiatric history is essential to achieve this. People suffering from generalized anxiety disorder, phobias or obsessive compulsive disorders, might never have seen a psychiatrist before. Careful questioning about long-lasting symptoms (e.g., ‘Have you always been a worrier?’ Have you always avoided travelling in cars/trains/planes?’) can reveal a long history of psychopathology. The mood fluctuations in bipolar disorder sometimes accentuate with age and retrospective diagnosis of a sub-clinical lifelong disorder can be made on a thoroughly taken history. You will need to actively ask about important issues such as mood symptoms, psychotic features, anxiety, sleep and appetite problems, suicidality.
PHARMACOLOGICAL HISTORY Obtaining an accurate pharmacological history is important as response to previous treatments and their side effects can inform current prescriptions. However, this can be more difficult than with younger adults as elderly patients might not remember the names of drugs they have been taking over the years. Your knowledge of older psychiatric treatments and interventions as well as older indications for certain types of treatments will help put the information into the right context7 . For example, ECT, lithium, chlorpromazine and haloperidol were the only treatments available for mental illnesses
until the 1950s when imipramine (the first antidepressant) was introduced; although the current use of antipsychotics is mainly for psychosis, low doses of neuroleptics used to be prescribed in the treatment of depression, anxiety and somatic symptoms; ECT, now mainly used for severe depression and catatonia, was frequently used in the treatment of various psychiatric disorders 30–40 years ago; admissions for treatment were more frequent and much longer than nowadays. Enquiring about the patient’s previous compliance with prescribed treatments, as well as the reasons for non-compliance, when this was the case, can reveal important information. Poor compliance can have various causes and most are similar to those in younger adults, for example, the patient is not convinced that trying a treatment would help, is lacking insight into their psychiatric problem, is experiencing side effects or unpleasant effects from the drugs, stops treatment when they feel better, stops after just a few days due to lack of effect etc. In elderly patients, especially those with cognitive deficits, poor compliance can be due to forgetfulness. This is a serious problem in this population with high levels of co-morbidity and chronic conditions and can lead to relapse of physical or mental condition, underor overdosing, withdrawal syndromes or other adverse drug reactions. There are various ways to address this such as, enhancing the doctor–patient relationship, psychoeducation, technical solutions (e.g. using dossette boxes), intensifying care (e.g, prompting by carer, administration of drugs by a carer, moving to a more supported accommodation) or, at the extreme, stopping some or all medication if none of the options work and there are associated risks8 .
FAMILY HISTORY There are understandable differences between taking a family history in a younger adult and an elderly patient. In the elderly, usually the parents of the patient would have died a long time ago, possibly at a younger age than one would expect to now, as a result of which there may not be a history of any problems with an onset in old age, for example dementia. Often the condition from which the parent was suffering may not be known, as the diagnosis may not have been given or may not have been known. Siblings, children, grandchildren and great grandchildren would now be part of the family history. Family interactions can be complex and exploring them can shed light on factors associated with the patient’s problems. It will be important to note if the patient is involved in looking after any young children in case child protection issues arise. The converse may also be true if the children or grandchildren are involved in caring for the patient and younger adult protection concerns arise. Any history of mental disorders in the family must be recorded when available, be it in the patient’s parents, children or grandchildren. This would represent third-party information and appropriate confidentiality must be maintained. A history of suicide in a first degree family member represents a risk factor for the patient9 .
PERSONAL HISTORY This would usually be of much greater length than that of a younger patient. Information on developmental milestones might not be available or relevant but educational attainment and work history will be important for assessing the impact of the psychiatric problem on their lives or when interpreting test results for dementia. It is also an important indicator of the premorbid level of intellectual functioning. Your patient might want to tell you about their war experiences which
DIAGNOSIS AND ASSESSMENT may have left important psychological marks on their lives. Many more significant life events would have taken place such as loss of parents, relatives and friends. Other kinds of losses such as perceived loss of social status due to retirement, loss of earnings and having to live on a meagre pension, are almost always present. They may have to be living at a lower standard than they were accustomed to and poverty is significant among the elderly10 . Retirement is a stressful life event for some11 . Circumstances of retirement may have precipitated depression. Symptoms of dementia interfering with their job may have led to early retirement on medical grounds. Gross inaccuracies in recalling family history, names and birthdays can be a clue of memory problems.
PAST AND PRESENT SOCIAL SITUATION This is a broad domain that must be explored in detail when assessing elderly patients. Social and medical care often go hand in hand in helping to improve the patient’s quality of life and minimize the risks. For example, a social history revealing a patient living alone, unable to care for himself and under a significant risk to health, might be the single most essential information which will change your short-term treatment plan from prescribing a treatment at home to transferring to hospital or other care facility. It may be helpful to start with the patient describing a typical day. This should yield rich information about their current circumstances, what they can and cannot manage and what help they are getting from family, friends and neighbours, and voluntary or statutory services. It will also reveal the degree of impairment and the risks to the patient and can point towards other available services which the patient would benefit from, for example day centre, sitting service. Risks that might need immediate attention can be revealed by asking about the patient’s participation in activities of daily living (ADLs). Can they attend to personal hygiene, are they able to do the house chores, use the cooker or the telephone, are they safe on the stairs, are they safe outside the house etc.? (see chapter 34). Try and obtain information on the finances of your patient and most importantly their ability to manage them. It is necessary to enquire about their current pensions (state or private), benefits and savings, and think about any other benefits they might be entitled to. You can always request social services, working in partnership, to do a full financial assessment. If the patient is unable to manage their finances, arrangements for this to be done by someone else must be made. Family and patient may need to be encouraged to make a lasting power of attorney (LPA) for both property and welfare, a will or an advance decision or at least to start thinking about where they want to live in the future, what kind of care would be acceptable to them etc. Information about the patient’s religion, values and beliefs must be recorded as this can play a great role in their life and must be taken into account when planning future care. A driving history would indicate whether the patient is at risk when driving. If there are issues, the patient or you might need to inform the DVLA.
PERSONALITY While a thorough personality assessment cannot normally be done in a first interview, keeping a careful eye on personality issues right from the beginning can be very useful. We usually take our personality into old age and a history of significant changes from the
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premorbid personality reported by the informant will sometimes be a clue to a diagnosis of frontal lobe dementia. Knowledge of premorbid personality traits can be helpful in identifying personality change caused by a mental illness. It may also suggest coping strategies which manifest as symptoms.
PSYCHOSEXUAL HISTORY As in younger adults, this is an area that can be relevant to your patients’ relationships and mental health as well as compliance with medication so offer to discuss this with them. Specific problems in the elderly include sexual dysfunction, the loss of sexual partner by death or serious illness and sexual urges in people with dementia living in care homes.
ALCOHOL AND DRUGS HISTORY Incidence of alcohol misuse in elderly is thought to be lower then in younger adults but a failure to identify patient’s presenting with alcoholism might contribute to the lower figures12 . With the increase in life expectancy it is predicted the actual number of cases with alcohol-related problems will increase in the following years13 . Presentation with a fall, confusion or medical complications may mask an underlying alcohol problem. Hence enquiring about current or past alcohol and drug use must be a routine part of the assessment. This should include the age when first used, development of the problem, quantity and frequency and presence of dependence syndrome for each substance used. If alcohol abuse has started in old age, the circumstances might reveal underlying loss, bereavement or depression. In this age group physical or psychiatric complications of alcohol abuse (e.g. cirrhosis, peripheral neuropathy, cognitive impairment) might have already developed and can be found in the context of continuing or past alcohol abuse. Also, effects of previously well-tolerated quantities of alcohol may increase due to changed physiology. Onset of memory problems can interfere with a person’s usual pattern of alcohol use, for example, by precipitating withdrawal in someone with alcohol dependency who forgets how to obtain the alcohol or causing acute intoxication or even dependency in someone with no prior history of abuse, but regular use, who repeatedly drinks his usual non-harmful amount to intoxication levels. Knowledge of the type of alcohol consumed can suggest strategies of changing the alcohol to one of lower strength and then gradually tapering the amount, effectively detoxifying the patient. One can use alcohol assessment screening tools but these need to be age-specific, as many of the more traditional rating scales lack validity. The Short MAST-G is commonly used, but others such as the Drinking Problems Index and Alcohol-Related Problems Survey, are used in more specialized settings. Physical complications of alcohol misuse are numerous, but commonly affect the stomach (ulceration), liver (alcoholic hepatitis, progressing to cirrhosis), blood (anaemia), nervous system (peripheral neuropathy – lack of sensation in legs) and can lead to instability and falls related to episodes of intoxication. Falls may lead to head injury and subdural hematoma. Alcohol may also alter the way in which medication is metabolized by the body and can accentuate the side effects of drugs such as opiates (commonly found in prescribed painkillers). Inadvertent benzodiapine dependence is common in the elderly. Again, this relates to a time when not enough was known about
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benzodiazepines and they were prescribed for anxiety or depression and continued for long periods resulting in dependence. A thorough history of use of these drugs would provide useful information about past illness.
FORENSIC HISTORY In elderly presenting for psychiatric assessment a forensic history is very rarely present. The number of elderly offenders has remained stable over the years; however, the number of elderly in prisons has increased sharply14 . When taking a psychiatric history in a usual community or hospital setting the interviewer may feel that asking about forensic history can offend the patient and is not relevant. However, it is worth exploring and should not be ignored. There is a risk of offending in people with frontal lobe dementia when this is associated with disinhibition, hoarding or obliviousness to social rules. Also, aggressive behaviour in all types of dementia is frequent, especially towards the carer. In Lewy body dementia, vivid hallucinations, hallucinatory behaviour and cognitive fluctuations can sometimes lead to high risk of harm to others. But even when these lead to serious incidents. Police are rarely involved and charges are often not brought.
REFERENCES 1. Gainotti G, Marra C. Determinants and consequences of poststroke depression. Curr Opin Neurol 2002; 15(1): 85–9. 2. Jillian RS, Wolfgang L, Melanie JP. Depression as a predictor of disease progression and mortality in cancer patients. Cancer 2009; 9999(9999). 3. Ely EW, Siegel MD, Inouye SK. Delirium in the intensive care unit: an under-recognized syndrome of organ dysfunction. Semin Respir Crit Care Med 2001; 22(2): 115–26.
4. Maurer J, Rebbapragada V, Borson S, Goldstein R, Kunik ME, Yohannes AM et al . Anxiety and depression in COPD: current understanding, unanswered questions, and research needs. Chest 2008; 134(4 Suppl): 43S–56S. 5. Ried LD, Tueth MJ, Handberg E, Kupfer S, Pepine CJ, the ISG. A study of antihypertensive drugs and depressive symptoms (SADD-Sx) in patients treated with a calcium antagonist versus an atenolol hypertension treatment strategy in the International Verapamil SR-Trandolapril Study (INVEST). Psychosom Med 2005; 67(3): 398–406. 6. Ritchie EA. Toxic psychosis under cortisone and corticotrophin. J Ment Sci 1956; 102(429): 830–7. 7. Moncrieff J. An investigation into the precedents of modern drug treatment in psychiatry. Hist Psychiatry 1999; 10(40): 475–90. 8. van Dulmen S, Sluijs E, van Dijk L, de Ridder D, Heerdink R, Bensing J. Patient adherence to medical treatment: a review of reviews. BMC Health Serv Res 2007; 7: 55. 9. Kim CD, Seguin M, Therrien N, Riopel G, Chawky N, Lesage AD et al . Familial aggregation of suicidal behavior: a family study of male suicide completers from the general population. Am J Psychiatry 2005; 162(5): 1017–19. 10. UK elderly fourth poorest in EU BBC News, 2009. 11. Bosse R, Aldwin CM, Levenson MR, Workman-Daniels K. How stressful is retirement? Findings from the Normative Aging Study. J Gerontol 1991; 46(1): P9–14. 12. O’Connell H, Chin A-V, Cunningham C, Lawlor B. Alcohol use disorders in elderly people – redefining an age old problem in old age. BMJ 2003; 327(7416): 664–7. 13. Nina L. Alcohol use amongst community-dwelling elderly people: a review of the literature. J Adv Nurs 1997; 25(6): 1227–32. 14. Yorston GA, Taylor PJ. Commentary: older offenders – no place to go? J Am Acad Psychiatry Law 2006; 34(3): 333–7.
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Mental State Examination in the Elderly Joanne Rodda and Zuzana Walker Department of Mental Health Sciences, University College London, UK
The Mental State Examination (MSE) provides a snapshot of a patient’s symptoms and signs at the time of the interview. The approach to the MSE in older adults is very similar to that in the younger adult population, although there are a number of important considerations. For example, a significant proportion of patients in old age psychiatry services present with cognitive impairment and there are generational differences between older and younger adults. Physical illness can also complicate the MSE; the assessment of mood can be difficult if someone is frail, immobile or in pain, and acute confusion can be mistaken for dementia, psychosis or mania. These and other factors mean that the observable manifestations of mental illness in the elderly often differ from those in younger adults.
presentation represents a change from the patient’s usual way of interacting. Psychomotor changes are often prominent in depression in the elderly7 – 9 although bradykinesia and reduced mobility in Parkinson’s disease can be difficult to distinguish from psychomotor retardation or apathy. There are a host of motor signs – e.g. dystonic movements, mannerisms and stereotypies – that may occur as a feature of schizophrenia, mania or organic disorder10,11 or as a result of side effects of medication. Hyperorality and stereotyped, utilization or repetitive behaviours are suggestive of pathology involving the frontal lobes, e.g. frontotemporal dementia10 .
SPEECH APPEARANCE AND BEHAVIOUR A great deal of information can be gained from simple observation of the patient walking into the room; for example, posture, gait, presence of abnormal movements, level of personal hygiene and appropriateness of attire can immediately direct the clinician towards important areas for further enquiry. A deterioration in dress presentation may reflect a decline in personal care; clothing can also give clues about disinhibition or dressing dyspraxia. The level of personal hygiene can clearly demonstrate personal neglect although a well-kempt appearance might be maintained by a carer. The level of general awareness and alertness may be affected by physical illness or drugs, and fluctuations may be associated with delirium1,2 or dementia with Lewy bodies3,4 . Too little or too much eye contact might suggest low mood or disinhibition although it may be necessary to make allowances for visual impairment. Similarly, hearing or visual impairment may result in the appearance of distractibility and confusion. Irritability and hostility are sometimes said to be more common in mania in older adults. However, objective evidence from the few studies available suggests that the presentation of mania in older adults is similar to that in their younger counterparts5,6 . Over-familiarity or disinhibition is suggestive of mania or frontal lobe syndromes and can be a feature of many types of neurodegenerative disorder. An older person may be more reserved in their interactions with others and so a level of familiarity or inhibition that fits into the realms of social acceptability may still represent a change from normal for that individual. Conversely, a gregarious person may always have been that way; information from relatives or carers is therefore often important to determine whether the current
In the elderly, speech can be affected by a number of factors unrelated to mental state, including ill-fitting dentures or oral pathology. An increase or decrease in the rate, quantity and/or volume of speech can be associated with mania and depression, respectively. Pressure of speech is characteristic of mania or frontal lobe involvement. In depression, poverty of speech may occur to a degree that the patient appears to be mute or dysphasic, although such a severe impairment in language is more frequently a result of neurodegenerative or cerebrovascular disease than functional illness. Circumstantiality and tangentiality occur in psychosis and mania, but are often related to dementia in the elderly. Similarly, flight of ideas is characteristic of mania but can also occur in frontal lobe syndromes. Nominal dysphasia is common in the early stages of Alzheimer’s disease when it would normally be associated with at least some degree of memory impairment. Conversely, in primary progressive aphasia (PPA) impairments in language precede deficits in other cognitive domains12,13 . Language deficits in PPA are predominantly expressive and usually associated with loss of fluency; in semantic dementia there is loss of expressive and receptive vocabulary in the presence of fluent but ‘empty’ speech10,14 . Clearly, it is important to ensure that any apparent receptive dysphasia cannot be accounted for by a hearing impairment and that an apparent expressive dysphasia is not in fact the result of dysarthria. Dysphonia is a disorder of phonation due to inability to produce voice sounds using the vocal organs; this is distinct from dysarthria and can occur in Parkinson’s disease, stroke and other organic disorders15 or as a psychogenic phenomenon16 . Other abnormalities of speech are suggestive of specific disorders. For example, perseverative speech is almost pathognomonic of organic brain disease, particularly involving the frontal lobes. Verbal
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stereotypies, mannerisms, echolalia, paraphasia and neologisms also occur in organic (often frontal) syndromes although may also occur in mania and psychosis.
MOOD Elderly people may be less likely than younger adults to report sadness or dysphoria. This does not appear to be a cohort effect and has been reported in different generations of older adults17 ; whether this will hold true for the current young-old population is not known. The concept of ‘depression without sadness’ has, however, been criticized by some, who suggest that apathy, withdrawal and loss of vigour can represent a depletion or disengagement syndrome that reflects normal age-related changes18 . A similar picture may also result from physical illness due to chronic pain, fatigue and disability. Likewise, the bradykinesia and bradyphrenia of Parkinson’s disease can lead to difficulties in differentiating depressive from physical symptomatology. Apathy, loss of interest and motivation and even abulia may occur in dementia, particularly in subcortical19,20 and frontotemporal subtypes21 , and can overlap with or be misinterpreted as depression22,23 . Changes in mood may be also present in the prodromal stages of dementia, before cognitive deficits are apparent24 . In established dementia, affective disturbances are common and may present with behavioural changes25 – 27 . Given the overlap of symptomatology, it is helpful to pay close attention to the presence of biological features of depression, particularly diurnal mood variation, appetite, early morning waking and anhedonia. Cognitive symptoms of guilt, helplessness and worthlessness are also useful pointers towards a depressive disorder. Emotional lability can be present in affective disorder and psychosis but can also be a feature of organic syndromes, e.g. cerebrovascular disease28 , Parkinson’s disease29 and other brain pathology30 , and may be confused with depression. Euphoria is a feature of mania and frontal lobe dysfunction, and may be present in other organic disorders.
THOUGHT Thought Form As in younger patients, psychotic illness in the elderly can be associated with a broad spectrum of abnormalities of thought form, e.g. circumstantiality, flight of ideas, loosening of associations (from tangentiality through to word salad) and, at the other extreme, thought block. However, apparent thought disorder in the elderly may represent confusion or language disorder as a result of delirium or neurodegenerative illness. Careful attention to the overall picture, including the context of the patient’s presentation and simple cognitive testing, can help to clarify the situation.
Thought Content Delusions are fixed beliefs out of keeping with an individual’s social, cultural and religious background, which are based on unsound reasoning and are maintained even in the presence of evidence to the contrary. In the elderly, delusions may form part of a psychotic or affective illness but are also common in delirium and dementia. In delirium, delusions are often fleeting and persecutory. In dementia, delusions of theft are common and often relate to misplacement of objects. Well-formed delusional systems are uncommon in dementia
but do occur. Delusional misidentification is also common in organic disorder31 , e.g. patients with dementia may insist that their spouse or even their own reflection in the mirror is an impostor. As in young adults, delusions can be sub-classified into several types, e.g. persecutory, grandiose, nihilistic and bizarre delusions, and delusions of jealousy. Autochthonous or primary delusions arise spontaneously and ‘out of the blue’ while secondary delusions occur as a result of some other experience, e.g. secondary to hallucinations or affective disturbances. Primary delusions in the elderly suggest functional rather than organic disorder. Delusions must be differentiated from overvalued ideas, which are beliefs that may not be unreasonable but are pursued to an unreasonable degree by the patient. Overvalued ideas are often associated with personality disorders. Obsessions are recurrent and persistent thoughts, images or impulses that the patient tries to but is unable to resist. They may occur in the context of an obsessive disorder but can also be a feature of depression or dementia. Sometimes repeated checking in dementia is related to anxiety and forgetfulness rather than obsessive–compulsive behaviour and can present a diagnostic challenge, particularly in the early stages.
Passivity Phenomena Thought insertion and withdrawal, thought broadcast and ‘made actions’ represent a disintegration of boundaries between the self and the outside world and are typical of a functional psychotic disorder rather than dementia or delirium.
PERCEPTION A hallucination is a perception in the absence of an external stimulus and may occur in any modality (auditory, visual, tactile, olfactory, gustatory, somatic) in the context of psychosis, affective disorder, organic disorder or delirium. Sensory impairment, both visual and auditory, is particularly important in older people and predisposes to hallucinations. Charles Bonnet’s syndrome of visual hallucinations in people with visual impairment in the absence of psychiatric or neurological illness is well known. These hallucinations are typically complex, not distressing and are usually associated with a good degree of insight. The most common cause is age-related macular degeneration (see Schadlu et al .32 for a recent detailed review). Auditory hallucinations (typically of music) occurring in clear consciousness in people with hearing impairment are also common and have been described as an auditory form of Charles Bonnet syndrome33 . The pathophysiology underlying these experiences may relate to deafferentiation of visual or auditory cortical structures, resulting in hyperexcitability and increased spontaneous activity34 . Sensory impairment is also an important maintaining factor for hallucinations occurring in the context of schizophrenia or other disorders. Auditory hallucinations occur in schizophrenia regardless of the age of onset, although in late-onset psychotic illness visual and olfactory hallucinations are also relatively common35 . It is important to ensure that an acute confusional state or other organic cause is excluded before new-onset hallucinations in the elderly are attributed to functional illness. Visual hallucinations, typically of people or animals, are one of the core features of dementia with Lewy bodies and are often associated with some degree of insight4 . Illusions are false internal perceptions that result from a combination of imagery and the perception of a real external object. They are common in people with visual impairment as well as in psychotic
DIAGNOSIS AND ASSESSMENT or organic disorder and are accentuated by affect and poor attention. Sensory distortions are changes in the perceived quality or intensity of a stimulus (e.g. hyperacusis) and are suggestive of organic disorder or drug intoxication. Perceptual abnormalities must be discriminated from visual agnosia, which is the failure to recognize objects despite normal function of the eye.
COGNITION General observation throughout the interview will provide information about cognition, e.g. the general level of orientation, the presence of confabulation, repetition of questions or statements and the ability to follow the conversation and to remember facts and names. The presence of hearing impairment, anger, irritability, anxiety, depression and psychosis can lead to an underestimation of cognitive ability and it is important to bear these factors in mind. Conversely, older people with marked cognitive impairment can maintain a fac¸ade that is convincing enough to mask their deficits in the absence of collateral history or objective cognitive testing, particularly in the context of a high premorbid level of intellectual ability. Memory is relatively well preserved in the early stages of some dementias and in these cases deficits in other cognitive domains may only become apparent on formal testing. Examples include visuo-spatial impairments in dementia with Lewy bodies4 or deficits in sequencing and executive function in frontotemporal dementia10 . Relatives’ accounts of cognitive function can also be inaccurate, e.g. due to expectations of increasing forgetfulness with ageing, the insidious nature of their relative’s decline or difficulties in accepting the change in their loved one and its significance. It is therefore important to include at least some form of objective cognitive testing during even the most basic examination of mental state. The Mini Mental State Examination (MMSE)36 is the most widely used cognitive screening tool in clinical practice, although it is weighted towards verbal memory and does not include items to assess executive function. Furthermore, individuals with high premorbid intellectual function may score well within the normal range despite marked cognitive and functional decline from previous levels37 . More detailed brief assessment scales include the Addenbrooke’s Cognitive Examination – Revised (ACE-R)38 , Modified Mini Mental State Examination (3 MS)39 and Cognitive Abilities Screening Instrument (CASI)40 , although all take longer to complete than the MMSE41 . Supplementing the MMSE with other brief tests like letter fluency (FAS)42 and the clock drawing test43,44 may be a practical compromise for the initial assessment and to guide the need for more detailed neuropsychological assessment.
INSIGHT Insight is a fluid and multifaceted phenomenon and has been conceptualized in many ways. The dimensions of insight in psychosis have been summarized as: (i) recognition of the illness, (ii) attribution of the illness to a mental disorder, (iii) awareness of the benefit of treatment, and (iv) awareness of the social consequences of the mental disorder45 . Insight in dementia is also a complex entity, and both explicit and implicit awareness are worth considering46 . For example, an individual may deny any problem with their memory but acknowledge that they have performed poorly on a test or need to use memory aids at home to ensure that they remember appointments. It can sometimes be difficult to discriminate between lack of insight and cognitive impairment itself; this is particularly relevant when considering medication compliance.
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It has been suggested that some individuals have insight into subtle cognitive deficits before they are apparent on objective testing, and that as these objective cognitive deficits develop, insight progresses in an inverse U-shaped curve so that ultimately there is established dementia with little insight47 . However, insight in mild cognitive impairment is variable48 and the significance of subjective memory complaints in the absence of objective cognitive deficits is as yet uncertain.
REFERENCES 1. Burns A, Gallagley A, Byrne J. Delirium. J Neurol Neurosurg Psychiatry 2004; 75(3): 362–7. 2. Taylor D, Lewis S. Delirium. J Neurol Neurosurg Psychiatry 1993; 56(7): 742–51. 3. Ferman TJ, Smith GE, Boeve BF et al . DLB fluctuations: specific features that reliably differentiate DLB from AD and normal aging. Neurology 2004; 62(2): 181–7. 4. McKeith IG, Dickson DW, Lowe J et al . Diagnosis and management of dementia with Lewy bodies: third report of the DLB Consortium. Neurology 2005; 65(12): 1863–72. 5. Benedetti A, Scarpellini P, Casamassima F et al . Bipolar disorder in late life: clinical characteristics in a sample of older adults admitted for manic episode. Clin Pract Epidemiol Ment Health 2008; 4: 22. 6. Broadhead J, Jacoby R. Mania in old age: a first prospective study. Int J Geriatr Psychiatry 1990; 5: 215–22. 7. Brodaty H, Luscombe G, Parker G et al . Increased rate of psychosis and psychomotor change in depression with age. Psychol Med 1997; 27(5): 1205–13. 8. Parker G. Classifying depression: should paradigms lost be regained? Am J Psychiatry 2000; 157(8): 1195–1203. 9. Parker G, Roy K, Hadzi-Pavlovic D, Wilhelm K, Mitchell P. The differential impact of age on the phenomenology of melancholia. Psychol Med 2001; 31(7): 1231–6. 10. Neary D, Snowden JS, Gustafson L et al . Frontotemporal lobar degeneration: a consensus on clinical diagnostic criteria. Neurology 1998; 51(6): 1546–54. 11. Peralta V, Cuesta MJ. Motor features in psychotic disorders. I. Factor structure and clinical correlates. Schizophr Res 2001; 47(2–3): 107–16. 12. Mesulam MM. Primary progressive aphasia – differentiation from Alzheimer’s disease. Ann Neurol 1987; 22(4): 533–4. 13. Rogalski EJ, Mesulam MM. Clinical trajectories and biological features of primary progressive aphasia (PPA). Curr Alzheimer Res 2009; 6(4): 331–6. 14. Hodges JR, Patterson K. Semantic dementia: a unique clinicopathological syndrome. Lancet Neurol 2007; 6(11): 1004–14. 15. Merati AL, Heman-Ackah YD, Abaza M et al . Common movement disorders affecting the larynx: a report from the neurolaryngology committee of the AAO-HNS. Otolaryngol Head Neck Surg 2005; 133(5): 654–65. 16. Seifert E, Kollbrunner J. Stress and distress in non-organic voice disorder. Swiss Med Wkly 2005; 135(27–28): 387–97. 17. Gallo JJ, Rabins PV, Anthony JC. Sadness in older persons: 13year follow-up of a community sample in Baltimore, Maryland. Psychol Med 1999; 29(2): 341–50. 18. Adams KB. Depressive symptoms, depletion, or developmental change? Withdrawal, apathy, and lack of vigor in the Geriatric Depression Scale. Gerontologist 2001; 41(6): 768–77.
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19. Dujardin K, Sockeel P, Devos D et al . Characteristics of apathy in Parkinson’s disease. Mov Disord 2007; 22(6): 778–84. 20. Moretti R, Torre P, Antonello RM, Cazzato G. Behavioral alterations and vascular dementia Neurologist 2006; 12(1): 43–7. 21. Chow TW, Binns MA, Cummings JL et al . Apathy symptom profile and behavioral associations in frontotemporal dementia vs dementia of Alzheimer type. Arch Neurol 2009; 66(7): 888–93. 22. Starkstein SE, Ingram L, Garau ML, Mizrahi R. On the overlap between apathy and depression in dementia. J Neurol Neurosurg Psychiatry 2005; 76(8): 1070–74. 23. Tagariello P, Girardi P, Amore M. Depression and apathy in dementia: same syndrome or different constructs? A critical review. Arch Gerontol Geriatr 2009; 49(2): 246–9. 24. Onyike CU, Sheppard J M, Tschanz JT et al . Epidemiology of apathy in older adults: the Cache County Study. Am J Geriatr Psychiatry 2007; 15(5): 365–75. 25. Lyketsos CG, Olin J. Depression in Alzheimer’s disease: overview and treatment. Biol Psychiatry 2002; 52(3): 243–52. 26. Olin JT, Schneider LS, Katz IR et al . Provisional diagnostic criteria for depression of Alzheimer disease. Am J Geriatr Psychiatry 2002; 10(2): 125–8. 27. Verkaik R, Francke AL, van Meijel B, Ribbe MW, Bensing JM. Comorbid depression in dementia on psychogeriatric nursing home wards: which symptoms are prominent? Am J Geriatr Psychiatry 2009; 17(7): 565–73. 28. O’Brien J. Behavioral symptoms in vascular cognitive impairment and vascular dementia. Int Psychogeriatr 2003; 15(suppl 1): 133–8. 29. Phuong L, Garg S, Duda JE, Stern MB, Weintraub D. Involuntary emotional expression disorder (IEED) in Parkinson’s disease. Parkinsonism Relat Disord 2009; 15(7): 511–15. 30. Richter RW. The pathophysiology of emotional lability: many paths to a common destination. Am J Geriatr Pharmacother 2005; 3(suppl A): 9–11. 31. Fleminger S, Burns A. The delusional misidentification syndromes in patients with and without evidence of organic cerebral disorder: a structured review of case reports. Biol Psychiatry 1993; 33(1): 22–32. 32. Schadlu AP, Schadlu R, Shepherd JB, III. Charles Bonnet syndrome: a review. Curr Opin Ophthalmol 2009; 20(3): 219–22. 33. Griffiths TD. Musical hallucinosis in acquired deafness. Phenomenology and brain substrate. Brain 2000; 123(10): 2065–76. 34. Burke W. The neural basis of Charles Bonnet hallucinations: a hypothesis. J Neurol Neurosurg Psychiatry 2002; 73(5): 535–41.
35. Howard R, Rabins PV, Seeman MV, Jeste DV. Late-onset schizophrenia and very-late-onset schizophrenia-like psychosis: an international consensus. The International Late-Onset Schizophrenia Group. Am J Psychiatry 2000; 157(2): 172–8. 36. Folstein MF, Folstein SE, McHugh PR. ‘Mini-mental state’. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975; 12(3): 189–98. 37. O’Bryant SE, Humphreys JD, Smith GE et al . Detecting dementia with the mini-mental state examination in highly educated individuals. Arch Neurol 2008; 65(7): 963–7. 38. Mioshi E, Dawson K, Mitchell J, Arnold R, Hodges JR. The Addenbrooke’s Cognitive Examination Revised (ACE-R): a brief cognitive test battery for dementia screening. Int J Geriatr Psychiatry 2006; 21(11): 1078–85. 39. Teng EL, Chui HC. The Modified Mini-Mental State (3MS) examination. J Clin Psychiatry 1987; 48(8): 314–18. 40. Teng EL, Hasegawa K, Homma A et al . The Cognitive Abilities Screening Instrument (CASI): a practical test for cross-cultural epidemiological studies of dementia. Int Psychogeriatr 1994; 6(1): 45–58. 41. Cullen B, O’Neill B, Evans JJ, Coen RF, Lawlor BA. A review of screening tests for cognitive impairment. J Neurol Neurosurg Psychiatry 2007; 78(8): 790–99. 42. Benton A. Differential behavioural effects in frontal lobe disease. Neuropsychologia 1968; 6: 53–8. 43. Agrell B, Dehlin O. The clock drawing test. Age Ageing 1998; 27: 399–403. 44. Pinto E, Peters R. Literature review of the clock drawing test as a tool for cognitive screening. Dement Geriatr Cogn Disord 2009; 27(3): 201–13. 45. Amador XF, Strauss DH, Yale SA et al . Assessment of insight in psychosis. Am J Psychiatry 1993; 150(6): 873–9. 46. Howorth P, Saper J. The dimensions of insight in people with dementia. Aging Ment Health 2003; 7(2): 113–22. 47. Reisberg B, Gauthier S. Current evidence for subjective cognitive impairment (SCI) as the pre-mild cognitive impairment (MCI) stage of subsequently manifest Alzheimer’s disease. Int Psychogeriatr 2008; 20(1): 1–16. 48. Roberts JL, Clare L, Woods RT. Subjective memory complaints and awareness of memory functioning in mild cognitive impairment: a systematic review. Dement Geriatr Cogn Disord 2009; 28(2): 95–109.
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The Physical Examination: A Guide for Old Age Psychiatrists Stephen Todd, John O’Hare, Bernadette McGuinness and A. Peter Passmore Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, The Queen’s University of Belfast, Belfast, UK
INTRODUCTION
CONSIDERATIONS
The medical and psychiatric history obtained from the patient and informant, together with the mental status assessment, provide the majority of the information required in the evaluation of the older person presenting to the old age psychiatrist. However, the physical examination retains a crucial role in the evaluation of the older person for several reasons (Table 22.1). First, it is an expected component of the consultation by the patient and/or their relative or carer and assists in developing the doctor–patient relationship. Second, a particular physical sign or constellation of signs will increase or decrease the pretest probabilities in the differential diagnosis under consideration following the history. Third, a more rational and focused plan of investigation will be instituted. Fourth, serial examination over time allows the clinician to observe the course of the disease, assess the effectiveness of any treatments commenced, and, if necessary, reconsider the diagnosis in the light of these data. Fifth, on occasions, an adequate history may not be obtainable, for example in delirium. The physical examination therefore assumes greater weight in determining further management until such history becomes available. Finally, co-morbidity is the rule rather than the exception in the older person. Commonly, there will be several aetiologies for a particular presenting complaint. The old age psychiatrist assesses the older person in a variety of settings, including the home, clinic, hospital ward, or institution, and may be the first or only contact that person may have with a clinician. Therefore, the old age psychiatrist should have the skill and ability to perform a brief but thorough physical examination, interpret the findings, plan a logical series of investigations, and determine if referral to a specialist, including other members of the multidisciplinary team, is indicated1 .
A number of differences between older and younger people are reflected in the pattern and presentation of illness (Table 22.2). First, diseases that commonly occur in older people have taken many years, sometimes decades, to develop. Examples of such chronic ‘degenerative’ diseases are atherosclerosis, cancer, degenerative joint disease, and neurodegenerative disorders, such as Parkinson’s and Alzheimer’s diseases. Second, co-morbidity is common and interacts with normal physiological ageing changes of the body to modify presentation of disease. Impairment of physiological homeostatic mechanisms results in reduced capacity to cope with changes in the body (brought about by disease) or in the environment (such as absence of a carer or admission to hospital). Thus, the older person will be more severely affected by an insult that might be relatively minor to a younger adult. These ‘reduced reserves’ of older age also lead to slower recovery from an acute insult. For example, hospital length of stay is twice that of younger adults. However, even old, seriously ill individuals can recover if given sufficient time and support. Third, in older people symptoms of disease often are less specific and uninformative, making the task of establishing the diagnosis/diagnoses more challenging for the clinician. This non-specific mode of presentation often takes the form of a ‘giant of geriatrics’ syndrome – instability (falls); immobility (‘off feet’ or ‘off legs’); incontinence; intellectual impairment (delirium and dementia). However, a thoughtful approach and careful attention during physical examination will frequently direct the choice of investigations and treatment. Some practical considerations in the conduct of the physical examination should be kept in mind and will reap considerable reward in the information obtained (Table 22.3). Time and patience are necessary virtues of clinician and patient.
Table 22.1 Role of the physical examination in the older person Expectation by patient and/or relative in consulting a doctor Provides additional, pertinent information to history obtained Allows judicious use of investigations and resource Repeated assessment permits observation of disease course and therapeutic effects Detection of contributory or important co-morbidity
Table 22.2 Differences between older and younger people Background of chronic disease Impaired homeostasis/physiological changes of ageing Less specific presentation of disease
Principles and Practice of Geriatric Psychiatry, 3rd edn. Edited by Mohammed T. Abou-Saleh, Cornelius Katona and Anand Kumar 2011 John Wiley & Sons, Ltd
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Table 22.3 Practice points when examining the older person Older people may require longer, and need assistance, to: • Transfer from chair to standing • Mobilize into the consulting room • Transfer from chair to examination couch • Remove items of clothing • Replace items of clothing The examination may also be limited by: • Fatigue • Frailty • Pain • Breathlessness • Poor hearing or eyesight and missing aids • Confusion
myoclonus, or fasciculation of the tongue all require explanation. Wincing or grimacing indicates uncontrolled pain, which requires evaluation and alleviation. In the limbs, tremor may again be apparent. The position and posture of the limbs may suggest current or previous musculoskeletal or neurological problems. Speech will be assessed during the interview and might direct further testing to determine if there are one or more problems affecting comprehension, such as loss of hearing or receptive dysphasia; articulation and pronunciation, such as dysarthria, expressive dysphasia and dysphonia; or content, such as confusional states, delusional or psychotic disorders, or depression. Limitation of speech due to pain or dyspnoea indicates serious cardiovascular and/or respiratory compromise or perhaps profound anaemia.
Examination The student and doctor in training are encouraged to take the time to follow a standard scheme of examination for each body system and to repeat this scheme again and again not in a thoughtless way but with consideration to each point in the scheme, the finding elicited being examined for its significance in light of the other available data. Such an approach will produce a skilled clinician who can not only perform a rapid and seamless physical examination but also detect pertinent physical signs of relevance to the care of the older person.
GENERAL EXAMINATION During the Interview Physical examination commences on first meeting the older person, continues during the interview, and concludes with the ‘formal’ examination. Observation is thus the key initial tool, later to be supplemented, to a greater or lesser degree, by inspection, palpation, percussion and auscultation. Brief mention is made of the carer. Attention to carer demeanour and their relationship with the patient is important. Mental and physical ill health in the carer may adversely impact on the patient. The general appearance of the clothes, face and hands, including nails, may be the first clue to self-neglect or neglect or abuse from a carer, depression, or functional decline in completion of basic activities of daily living due to underlying disease(s). Body habitus may suggest malnourishment or cachexia. The handshake allows closer inspection of hands and nails and will also permit observation of tremor, whether resting or action, wasting of the small muscles, joint swelling or stiffness, or loose jewellery, for example, that will assist in directing enquiry and subsequent examination. Ability to transfer, requirement for an aid or an arm, and gait provide information on functional ability and may suggest dysfunction at various levels of the musculoskeletal and neurological systems which will require more detailed scrutiny. Observation of the face during the interview may reveal the blank appearance of Parkinson’s disease or the lack of expression and poor eye contact of depression. Asymmetry in facial appearance may indicate neurological dysfunction, for example due to stroke or Bell’s palsy. Less obvious, perhaps, are symmetrical changes in facial appearance, such as the pallor of anaemia, the fat deposition and telangiectasia of Cushing’s syndrome, or the proptosis and lid retraction of an overactive thyroid gland. Abnormal movements may be noted during the interview. In the head and face, titubation, orofacial dyskinesia, facial tics or
The general examination continues from and expands on observations made during the interview. A general ‘head to toe’ inspection of the patient will take closer note of the hands, face, head and neck, nutritional and hydration status, and the presence of abnormal swellings and masses. A systematic approach to the hands will inform the examiner on the presence of a multitude of systemic disorders. The nails may be pitted in psoriasis or clubbed in a number of respiratory, cardiac, gastrointestinal and other disorders. The pattern and distribution of swelling and deformity of the small joints may suggest the presence of osteoarthritis, rheumatoid arthritis or psoriatic arthropathy. Abnormal pigmentation of the skin may indicate anaemia if pale or chronic liver disease if jaundiced. Atrophy of the small muscles may be a marker of generalized weight loss and ill health or suggest median nerve entrapment at the wrist if isolated to the thenar eminence. Closer inspection of the eyes may also suggest anaemia or liver disease if there is pallor of the conjunctiva or jaundice of the sclera, respectively. Aphthous ulceration of the mouth is a marker of ill health. The presence of oral thrush can suggest recent antibiotic therapy, deficient oral hygiene or poorly controlled diabetes mellitus. Poorly fitting dentures can cause trauma. The condition of teeth that are present should be noted. Poor dentition can cause pain and reduction in oral intake. The neck should be inspected for the presence of masses and the thyroid gland palpated before and while the patient swallows a glass of water. This should prompt general consideration of thyroid status and evidence of over- (warm sweaty hands, tachycardia, particularly atrial fibrillation, or tremor) or under- (cold, hoarseness, bradycardia, ‘peaches and cream’ complexion) activity. The cervical lymph nodes should be palpated. Localized or generalized enlargement will be confirmed by subsequent palpation of axillary and inguinal chains. The skin should be exposed, with judicious use of a gown or drape, to assess colouration and pigmentation and characterize contusions, rashes, masses or tumours. Skin turgor in older people is less reliable than in younger adults as an indicator of hydration. Dryness of mucous membranes or axillae and sunken eyes are suggestive of dehydration whereas a moist tongue is evidence against dehydration. Further evaluation of hydration follows in the cardiovascular section.
CARDIOVASCULAR SYSTEM The patient should be positioned at forty-five degrees with neck and chest exposed. While palpating the radial pulse at the wrist, the examiner should note the rate and rhythm. Atrial fibrillation is
DIAGNOSIS AND ASSESSMENT the commonest arrhythmia in older people and is a strong risk factor for cerebral infarction. The character of the pulse is better assessed by palpation of the carotid artery. The blood pressure is measured both lying and after standing for two minutes. Falls are common in older patients, particularly in those with dementia. Postural hypotension is indicated by a fall of 20 mmHg or greater on standing for at least one minute. The face should be inspected briefly with consideration of jaundice or xanthelasma at the eyes and cyanosis of the lips and tongue. In the neck, the right internal jugular vein is inspected for the jugular venous pressure (JVP), noting the vertical height above the sternal notch and the character. The carotid arteries are palpated separately, noting the character. Inspect the praecordium for scars, deformity, position of the apex beat and pulsations. Palpation for the apex beat should consider the position and character. A laterally displaced apex beat can denote left ventricular dilatation. Tapping, thrusting and heaving beats occur in mitral stenosis, mitral regurgitation and left ventricular hypertrophy, respectively. Auscultation is done in the area of maximal acoustic advantage for each of the four valves – apex (mitral); lower left sternal edge (tricuspid); second left (pulmonary) and right (aortic) intercostal spaces. The examiner listens separately to each phase of the cardiac cycle. The first and second heart sounds should be identified and considered normal or abnormal in intensity. The presence of added sounds (extra heart sounds or murmurs) is considered, noting location in the cardiac cycle, character and position heard maximally. Added sounds may be accentuated by repositioning the patient – left lateral for mitral stenosis and upright for aortic regurgitation. With the patient sitting forward, the examiner may inspect and palpate for sacral oedema. The peripheral pulses should be palpated and other evidence of peripheral vascular disease, such as cool dusky skin, loss of hair and prolonged capillary refill, and peripheral oedema sought. Other signs to consider during later examination are dullness to percussion and reduced breath sounds (pleural effusion), inspiratory crepitations (pulmonary oedema), hepatomegaly (right ventricular failure) and a pulsatile epigastric mass (abdominal aortic aneurysm).
RESPIRATORY SYSTEM During the general inspection, notice whether the subject is dyspnoeic or using accessory muscles of respiration. In the hands, observe for tar staining, clubbing, anaemia or wasting of small muscles. The respiratory rate should be counted. In the face, unilateral meiosis and ptosis may suggest Horner’s syndrome (damage to the sympathetic nervous system). The contents of the sputum pot should be inspected. Listen for the high-pitched inspiratory note of stridor. In the neck, palpate for tracheal position and presence of cervical lymphadenopathy. Expose the chest completely and place the patient in a seated position. Both front and back of the chest should be examined with the following suggested scheme. First, inspect for scars and deformity and assess the degree and symmetry of expansion on maximal inspiration. Expansion is then assessed by palpation. Next, palpate for tactile vocal fremitus. The position of the apex beat may suggest mediastinal displacement. Chest percussion compares left side with right side as the examiner progresses down the chest, not forgetting apices and axillae. The percussion note may be dull, for example with pleural effusion or consolidation, or resonant, with pneumothorax or emphysema. Finally,
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the chest is auscultated. The character of the breath sounds, whether normal or bronchial, and their intensity is noted. The presence, location and timing of added sounds are then considered. Crepitations or crackles may be pan-inspiratory and in the lower zones in pulmonary oedema or end-inspiratory and with either an upper or lower zone location in pulmonary fibrosis. Wheeze is generally expiratory and polyphonic in chronic obstructive pulmonary disease (COPD). Expiration is prolonged in COPD. Asthma is less prevalent than COPD in older people.
GASTROINTESTINAL SYSTEM The abdomen should be completely exposed and the patient recumbent with one pillow to support the head. On general inspection, the examiner should have appreciated body habitus. In the hands, evidence of chronic liver disease such as clubbing, white nails, palmar erythema or Dupuytren’s contracture may be noted. Bruising, scratch marks and spider naevi may be noted on the torso. Jaundice is best appreciated at the sclera. The mouth should be illuminated and inspected for stomatitis, glossitis and ulceration. Parotid enlargement and, in men, gynaecomastia are also pointers to chronic liver disease. The abdomen should be inspected for scars, masses, bruising, distension, hernia and prominent veins. The examiner should also bend down to inspect from the side as masses may be visible. Abdominal movement on respiration is then noted. The patient should be asked to indicate the site of pain, if present. On light palpation of all areas of the abdomen, the examiner should observe for evidence of pain, including wincing, grimacing or guarding. Each region should be deeply palpated in turn for masses if no pain is elicited. Continue to palpate specifically for the presence and location of hepatomegaly and splenomegaly. The kidneys may be bimanually palpable. The groins are palpated for adenopathy and hernia. Percussion of the abdomen starts in the midline and works toward the flank. If dullness is noted the examiner should seek to demonstrate if it shifts on repositioning the patient. Auscultate for the presence of bowel sounds and for bruits over the renal areas. The gastrointestinal examination is completed with digital rectal examination.
NEUROLOGICAL SYSTEM Neurological examination is an essential component of the evaluation of every older person presenting to the old age psychiatrist. An experienced clinician will complete a thorough screening assessment in a few minutes and conduct a detailed follow-up examination as indicated with only minimum further effort. Neurological examination is crucial for several reasons (Table 22.4). Observation during interview and general examination of tremor or blank facies will direct the examiner towards other evidence of Parkinsonism, whereas a drooping lip or stiff, immobile limb might suggest stroke and a search for asymmetric upper motor neurone deficits. However, it is recommended that a standard scheme is followed to ensure thorough assessment. Table 22.4 Importance of neurological examination Diagnostic criteria specify neurological signs2 – 4 Development of signs can mark disease progression Recognize side effects of psychiatric medications Ability to localize pathology by pattern of signs
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Cranial Nerves
Limbs
Assessment of olfaction is generally limited to an enquiry regarding the sense of smell. The eyes are examined ‘from out to in’. Visual acuity, corrected with the person’s glasses, is assessed in each eye with a Snellen chart. If the top line cannot be read, acuity should be recorded as the best of finger counting, hand movement, or light appreciation. Knowledge of visual acuity is important in cognitive testing. Visual fields are assessed by confrontation to the examiner’s (which are assumed to be normal). The examiner should be seated at least one metre from the patient and on the same level. Each eye is tested in turn and, as a minimum, all four quadrants in each eye should be probed. Any deficit detected must be mapped in detail. The presence of visual inattention is assessed by stimulating both fields simultaneously. Extraocular muscle function is assessed by asking the subject to track a moving object through a horizontal and then a vertical arc from the neutral point. The examiner may place a hand on the patient’s forehead to prevent movement. In addition to the direction of reduced or absent movement, the presence of diplopia and direction and speed of nystagmus is noted. The pupils are inspected for size, shape and regularity and compared for equality. The direct reaction of the pupil to light and the consensual reaction of its pair are tested with a bright light shone from the temporal side. Reaction of the pupils to accommodation is tested by asking the patient to change focus from the distance to an object placed close to the face. Cataract may be detected by absence of the red reflex. The corneal reflex is elicited using a strand of cotton wool advanced from the temporal side. On fundoscopy, evidence of retinopathy from diabetes mellitus or hypertension and papilloedema from raised intracranial pressure should be sought. A scheme of examination of lower cranial nerves is described, although it should be noted that this does not follow each nerve in sequence. Thus, the examiner should remain cognisant of what is being tested. A simple command, followed by demonstration of the desired manoeuvre facilitates compliance with motor examination not only of cranial nerves but also the limbs, to be described below. Instructions to ‘raise your eyebrows’, ‘close your eyes tightly’, ‘puff/blow out your cheeks’, ‘show me your teeth’ and ‘clench your teeth’ assess motor function of the facial and trigeminal nerves. The ability to raise the eyebrow in the presence of ipsilateral lower facial palsy indicates upper motor neurone aetiology. Sensation is tested in the dermatome of each of the three branches of the trigeminal nerve by touching forehead, cheek and jaw on each side. The sensation of taste is not routinely assessed clinically. Several functions should be assessed once the patient is instructed to ‘open your mouth’. While the tongue rests in the floor of the mouth fasciculation may be noted. Movement of the uvula to one side on the command ‘say ah’ indicates a palsy of the contralateral glossopharyngeal nerve. The gag reflex is tested using an orange stick to press on each side of the oropharynx. Finally, the patient is asked to ‘stick out your tongue’. A deviated tongue points to the side of the lesion. Assessment of motor function is completed by asking the patient to ‘look to the side’ (sternomastoid) and ‘shrug your shoulders’ (trapezius). Hearing is assessed informally by asking the patient to repeat a phrase whispered into each ear in turn. Primitive reflexes, such as pouting or palmo-mental, may be present in advanced dementia.
Tables 22.5 and 22.6 summarize the scheme of neurological examination of the limbs.
Table 22.5 Neurological examination of the upper limbs Inspection • wasting • fasciculation Tone Power • pronator drift • shoulder abduction (C5,6) • elbow flexion (C5,6) • elbow extension (C6,7) • wrist & finger extension (C7) • wrist flexion & grip (C8) Coordination • finger-nose • rapid alternating movements Reflexes • biceps (C5,6) • supinator (C5,6) • triceps (C6,7) Sensation • pin-prick • vibration • joint position • light touch
Table 22.6 Neurological examination of the lower limbs Inspection • wasting • fasciculation Tone Power • hip flexion • knee flexion • knee extension • ankle dorsi flexion • ankle plantar flexion Coordination • heel-shin • foot tapping Reflexes • knee • ankle • plantar Sensation • pin-prick • vibration • joint position • light touch Gait
(L2,3) (L5,S1) (L3,4) (L4,5) (S1,2)
(L3,4) (S1,2)
DIAGNOSIS AND ASSESSMENT
Upper limbs (Table 22.5) Assessment of tone may be affected by voluntary or involuntary movement and is often confounded by the instruction to ‘relax’ or ‘let your arm go floppy’. Asking the patient to tap the foot can help. Reduced tone occurs in the early stage following stroke but usually indicates lower motor neurone pathology. The increased tone of longstanding upper motor neurone lesions eventually releases in a ‘clasp-knife’ pattern. In Parkinsonian syndromes, tremor superimposed on rigidity leads to a ‘cog-wheel’ pattern. Extrapyramidal signs may be caused by chronic neuroleptic use. Pronator drift remains a sensitive marker for weakness. One muscle group innervated from each cranial nerve root should be tested (Table 22.5). It is prudent to assess grip strength and function of the hand and fingers. Power is tested in the position of maximal activity and graded on a standard scale, according to age, build and gender. Stroke predominantly affects flexor muscles. If the deep tendon reflexes are increased, a positive Hoffmann’s reflex (flicking the nail of either the second, third or fourth finger will cause a flexion of the thumb) and finger jerk confirm hyperreflexia. Reinforcement, for example by clenching the teeth, may be required if a reflex appears absent. Coordination is assessed by the finger–nose test – assessing for intention tremor and past-pointing – and rapid, alternating hand movements – which may be slow and clumsy in cerebellar and extrapyramidal disorders. When testing sensation, the distribution of any abnormality should be determined and may be dermatomal (nerve root or spinal cord lesion), involve a single peripheral nerve territory (for example, carpal tunnel syndrome) or the ‘glove’ loss of a peripheral neuropathy. Testing for sensation may be unrewarding in subjects with dementia.
Lower limbs (Table 22.6) Tone is assessed during hip rotation and knee flexion. Clonus, a sustained, rhythmical contraction of muscles under sudden stretch,
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is checked at the knee and ankle and is present with increased tone from an upper motor neurone lesion. Each lumbosacral nerve root is tested for motor and sensory function. Loss of posterior column modalities is often found in normal elderly people. The plantar reflex (Babinski sign) is elicited by drawing the stimulus along the lateral border of the sole of the foot from posterior to anterior and then medially across the ball of the foot. Spreading of the toes and dorsiflexion (extension) of the great toe due to upper motor neurone pathology must be distinguished from a withdrawal response. In the heel–shin test the patient is instructed to slide the foot smoothly down the shin from the knee to the ankle and repeat. Rapid, alternating movement is tested by the patient tapping the foot on the ground. Finally, the gait is observed with the patient walking normally, turning and walking back. Walking heel to toe and performing Romberg’s test (the patient stands with the feet together and is asked to close their eyes) assesses cerebellar and posterior column function.
REFERENCES 1. Royal College of Psychiatrists. A Competency Based Curriculum for Specialist Training in Psychiatry: Specialist Module in Old Age Psychiatry. London: Royal College of Psychiatrists, 2006. 2. McKhann G, Drachman D, Folstein M et al . Clinical diagnosis of Alzheimer’s disease: report of the NINCDS-ADRDA Work Group under the auspices of Department of Health and Human Services Task Force on Alzheimer’s Disease. Neurology 1984; 34: 939–44. 3. McKeith IG, Dickson DW, Lowe J et al . Diagnosis and management of dementia with Lewy bodies: third report of the DLB Consortium. Neurology 2005; 65: 1863–72. 4. Roman GC, Tatemichi TK, Erkinjuntti T et al . Vascular dementia: diagnostic criteria for research studies. Report of the NINDSAIREN International Workshop. Neurology 1993; 43: 250–60.
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Investigations in Old Age Psychiatry Sujatha Merve1 and Robert C. Baldwin2 2
1 Chasefarm Hospital, Enfield, UK Manchester Royal Infirmary, Manchester, UK
INTRODUCTION This chapter reviews a range of laboratory and imaging investigations with which an old age psychiatrist should be familiar. Physical illness has been shown to be present in 20–80% of psychiatric patient populations surveyed1 . Physical illness of relevance to the presenting psychiatric symptoms is reportedly in the range 9–46%1 . Concomitant medical disorder was found in up to 63% of psychiatric patients presenting to an emergency department2 . However, a retrospective study demonstrated that only 0.8–4.0% of abnormal tests were clinically significant1 (defined as those that contributed to a diagnosis of a medical disorder not identified by history taking and physical examination and which led to a medical consultation or changed further management). Accordingly, some have argued against using routine batteries of tests1,2 . The older adult population may be an exception to this, as the chances of a physical illness presenting primarily with psychiatric symptoms is increased. Examples include delirium (infections, metabolic abnormalities, polypharmacy); dementia (thyroid disease, B12 deficiency); psychosis (substance withdrawal/toxicity, space occupying lesions in the brain); depression (anaemia, thyroid disease, some drugs, malignancy); mania (stroke, drug side effects); anxiety (thyroid disease, cardiac arrhythmia); and perceptual abnormalities (visual defects, migraine, temporal lobe epilepsy, withdrawal from drugs). Further, mental disorder may contribute to the onset of new physical illness or deterioration in an existing one due to factors such as self-neglect or cognitive difficulties. Investigations should be guided by findings from history taking, mental state examination and relevant physical examination. Unlike in general medicine, the role of laboratory and other investigations is mainly supportive and to rule out an organic aetiology of psychiatric presentations. However, there are several other reasons for conducting physical investigations in the older patient (Table 23.1). Ancillary investigations can aid diagnosis, especially in the dementias and in delirium. Many older patients have known physical comorbidity that requires further evaluation or are at high risk of common morbidities, which can affect management (ischaemic heart disease, anaemia, etc.). Because of self-neglect, those with dementia and depression may suffer under-nutrition and require investigation for this. Last, some psychiatric procedures and medication require pre- and/or post-testing (Figure 23.1).
Investigations may therefore be classified as primary or ‘routine’ (most patients receive them), secondary (indicated only in patients with certain clinical characteristics) and mandated (patients meeting certain criteria must have them) (Figure 23.1). The limitations of this approach should be recognized. Some tests (e.g. for neurosyphilis, see below) will show abnormal results very rarely but with important clinical implications. Others (e.g. full blood count or plasma viscosity) will often be slightly abnormal and of uncertain significance. A good deal of skill is required to interpret results in relation to a particular patient. An example of an investigation of immediate relevance to management is a patient with a history of depression now presenting with what appeared to be a recurrence but also with recent confusion and difficulty in walking. On computerized tomography (CT) brain scan he was found to have a glioma. In another instance a patient with dementia deteriorated with poor appetite and weight loss. Investigations revealed anaemia and a markedly raised C-reactive protein, found on further testing to be due to inflammatory bowel disease. Here investigations helped clarify whether it was dementia or comorbid pathology causing physical deterioration. Sometimes investigations are of uncertain relevance. An example is a patient presenting with late-onset psychosis and who was found to have a sodium of 125 mmol/l due to the syndrome of inappropriate antidiuretic hormone secretion (SIADH; see below) and a raised thyroid stimulating hormone (TSH) level caused by not taking thyroxine for former radio-iodine treated thyrotoxicosis. Optimizing these abnormalities made no obvious difference to her mental state, which improved only after the introduction of an antipsychotic agent. This also illustrates that even when there is an apparently obvious physical cause for an observed mental state, it is often necessary to treat psychiatric comorbidity as well as optimizing the management of physical disorder.
HAEMATOLOGICAL INVESTIGATIONS The full blood count (FBC) and differential count help detect various conditions, including anaemia (low haemoglobin, low red cell count, micro/macrocytosis), infections (raised white cell count, neutrophilia), allergies or parasitic infections (eosinophilia), blood malignancies (raised cell count, abnormal cells in blood smear) and effects of drugs on particular cell lines (neutropenia or
Principles and Practice of Geriatric Psychiatry, 3rd edn. Edited by Mohammed T. Abou-Saleh, Cornelius Katona and Anand Kumar 2011 John Wiley & Sons, Ltd
DIAGNOSIS AND ASSESSMENT Table 23.1 Reasons for conducting investigations in old age psychiatry To rule out causative organic physical illness To aid in the diagnosis of some psychiatric conditions (e.g. dementia) To assess secondary physical effects of the presenting psychiatric disorder To help assess the impact of known medical co-morbidities To screen for common co-morbidities not obvious at presentation but likely to affect management To screen prior to the commencement of some medications and procedures To monitor drug levels in the blood To monitor potential side effects of prescribed drugs
agranulocytosis with clozapine). The erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are non-specific tests that can point to infection, inflammation, anaemia, malignancy, temporal arteritis and autoimmune conditions. The ESR rises with advancing age and so becomes more difficult to interpret. The incidence of psychiatric symptoms with B12 deficiency has been reported to vary between 4% and 50% depending on the population studied3 . A correlation between serum cobalamin level and measures of cognitive function has been noted in some studies, although this has been disputed in those aged over 604 . Deficiency of folate may be more likely to cause depressive symptoms and a low B12 has been linked to psychosis5 . The true nature and reversibility of a B12 deficiency-induced dementia has been debated. In addition,
First-level (‘routine’) investigations
• Full blood count • Erythrocyte sedimentation rate (ESR) • C-Reactive protein (CRP) • Serum B12 and folate • Urea electrolytes • Thyroid function tests (TFT) • Liver functions tests (LFT) • Lipid profile • Gamma GT • Blood glucose • Calcium • Urine mid-stream specimen • ECG • Chest X-ray • CT/MRI brain scan
deficiency of folate has been linked to poorer response to antidepressant treatment6 . Confirmatory tests for the aetiology of vitamin B12 deficiency include gastric parietal cell antibodies, intrinsic factor antibodies and the Schilling test.
BIOCHEMISTRY Routine biochemistry may detect electrolyte disturbances, dehydration and abnormal organ functioning (kidney, liver). The commonest psychiatric presentation of most of these is delirium. In addition, biochemical investigations are used to monitor the metabolic side effects of antidepressants or antipsychotics (e.g. SIADH and abnormal liver function tests [LFT]) and mood stabilizers (urea and electrolytes and thyroid function with lithium). SIADH is characterized by hyponatraemia (levels below 125 mmol/l are usually symptomatic), low serum osmolality and inappropriately elevated urine osmolality. SIADH can develop early after initiation of drug therapy, especially with selective serotonin re-uptake inhibitors (SSRIs). Increasing age, female gender and medical co-morbidities are risk factors. Transient asymptomatic rise in LFT is not uncommon during the first few weeks of prescribing psychotropic drugs. Gamma glutamyl transpeptidase (γ GT) is elevated in liver disease, pancreatic disease, obesity and enzyme induction by drugs or alcohol, and 52% of alcohol dependent patients have been reported to have high γ GT7 . Due to its low specificity, γ GT is not indicated as a screening test for alcohol misuse. More specific is the carbohydrate-deficient transferrin (CDT) enzyme immunoassay. A random glucose above 11 mmol/l suggests diabetes. Hypoglycaemia can cause delirium and can be seen in depressed diabetic patients who take their medication but neglect to eat.
Mandated investigations
Second level (‘indicated’) investigations
• • • • •
•
VDRL HIV ELISA Serum/plasma osmolality Carbohydratedeficient transferrin Functional Imaging – Positron emission tomography (PET) – Single photon emission Computerized Tomography (SPECT) – Dopamine transporter (DAT) scan Immunological studies
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Related to prescribing or monitoring of psychotropic drugs
Prior to starting • Clozapine (FBC) • Lithium (U&E, TFT) • Antipsychotics (LFT, BM, lipids) • Antidementia drugs, some antidepressants (tricyclics and venlafaxine (ECG)
After starting • Clozapine (FBC) • Lithium (U&E, TFT) • Antipsychotics (LFT, glucose, lipids) • High-dose anti psychotics (ECG)
Pre-anaesthetic (Electroconvulsive therapy)
Drug level monitoring • Lithium • Other mood stabilizers (valproate, carbamazepine) • Clozapine
Figure 23.1 Types of investigations in old age psychiatry (see text for meaning of abbreviations)
• Routine haematology and biochemistry • ECG • Chest X-ray (if indicated)
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Thyroid function testing (TFT) should be performed because of the well-known association of depression and hypothyroidism, easily overlooked in the elderly, and because ‘apathetic hyperthyroidism’ can be mistaken for depression. Patients on lithium should undergo TFT every six months. Raised corrected serum calcium can indicate malignancy (metastasis, multiple myeloma and lung cancer) and these patients may present with depressive symptoms. Iron studies including serum ferritin and total iron binding capacity are performed to help diagnose the type of anaemia (iron deficiency, sideroblastic or anaemia of chronic disease). Because of the risk of the metabolic syndrome, fasting lipid screening is important in patients receiving antipsychotics. Waist measurement is a simple test of risk for this syndrome and there are international guidelines on waist measurement8 .
MICROBIOLOGY Mid-stream urine (MSU) assessment is usually carried out to assess patients with confusion. In a sample of 68 patients Gregory et al.2 reported an overall percentage of significant results in 3.1% of their review of general psychiatry patients. Kolman9 , though, studied older patients and found positive test results in 21% of patients. Noncontaminated samples are hard to obtain from patients with delirium or dementia.
SPECIALIZED BLOOD TESTS Syphilis The Venereal Disease Research Laboratory test, commonly known as the VDRL test, is a screening test for syphilis that measures antibodies to the spirochete Treponema pallidum in the blood or cerebrospinal fluid (CSF). The newer test analogous to this is the rapid plasma reagin (RPR). Treponema pallidum haemagglutination assay and the fluorescent Treponema antibody tests (TPHA/FTA ABS) are highly specific for Treponema antigens and are used at some centres as confirmatory tests, especially of CSF. Clinically significant results were found in 0.3% (0–0.6%) of psychiatric patients routinely screened1 . A retrospective study of all inpatients (mean age 74.5) undergoing syphilis screening in a UK hospital12 revealed that 16 of 423 tests were positive (3.8%). In four of the seven patients who received treatment, syphilis was identified as a likely contributor to the psychiatric presentation. The authors suggested that routine screening of elderly patients was justifiable where an organic aetiology was suspected, especially in dementia. Hilton13 , though, highlighted the importance of considering local epidemiology, risk factors, neurological/neuropsychiatric features and ethics prior to the routine screening of patients. In the guidance on dementia issued by the National Institute for Health and Clinical Excellence (NICE), routine testing for syphilis is not recommended14 .
RADIOLOGY The patient’s age correlates with the frequency of abnormal findings on chest X-ray10 . A review of 746 psychiatric admissions11 identified that the 9% of patients who had a significant X-ray finding also had concomitant physical signs and symptoms. Chest radiology of all patients presenting with psychiatric symptoms is not warranted, and clinical suspicion remains the best yardstick. It should always be performed on patients at risk of conditions like tuberculosis (homeless persons, alcohol/drug misuse and patients with HIV infection) and (ex-) smokers with weight loss. Chest radiography is usually performed routinely as a preanaesthetic screening tool prior to patients receiving ECT (some centres perform it on a mandatory basis on patients aged above 35). Endoscopy and barium X-ray tests of the gastrointestinal system may be indicated for patients with weight loss and microcytic anaemia. These investigations are sometimes poorly tolerated by psychiatric patients so advances in CT imaging are important. Helical CT scanning of the abdomen with oral contrast, besides being rapid and non-invasive, can identify a range of pathologies of the gut and other structures.
Immunology Psychiatric symptoms may be caused by systemic autoimmune diseases such as systemic lupus erythematosus, scleroderma, sarcoidosis, Sj¨ogren syndrome, primary vasculitides and antiphospholipid syndrome. The range of autoimmune antibodies found in the spectrum of conditions include antinuclear antibody (ANA), anti-DNA (single stranded or double stranded), anti-Ro, anti-La, anti-phospholipid antibodies, anti-smooth muscle, rheumatoid factor (RF), anti-neutrophil cytoplasmic antibodies (ANCA) and antibodies to thyroid peroxidase. Table 23.2 illustrates the more common tests in relation to some immunological conditions. Catatonia and some rare encephalopathies are associated with autoimmunity, e.g. anti-NMDAR antibodies15 .
NEUROIMAGING Focal neurological signs on physical examination or an acute change in the mental status not completely explained by other causes require
Table 23.2 Autoimmune conditions and relevant investigations Condition
Psychiatric presentation
Relevant tests
Systemic lupus erythematosus Hashimoto’s thyroiditis
Psychosis, delirium, depression, global cognitive deficits Dementia, delirium, hallucinations
Sj¨ogren’s syndrome Polyarteritis nodosa
Cognitive dysfunction Delirium, auditory and visual hallucinations, dementia Delirium, depression, hallucinations, cognitive dysfunction
Anti-nuclear, anti-double stranded DNA, antiphospholipid, anti-neuronal Thyroid antibodies (antithyroid peroxidase and antithyroglobulin), anti-neural antibodies Anti-nuclear, rheumatic factor Raised erythrocyte sedimentation rate (ESR), arterial biopsy Raised ESR, arterial biopsy
Temporal arteritis and polymyalgia rheumatica
DIAGNOSIS AND ASSESSMENT consideration of neuroimaging. Subdural haematoma is easily overlooked in older adults, especially when chronic. Fluctuating confusion, unsteady gait, falls and heavy alcohol use are all clues. Imaging is important if normal pressure hydrocephalus (cognitive impairment, gait disorder, incontinence) is suspected. On magnetic resonance imaging (MRI) the typical ‘fluid void’ sign may be seen but imaging alone is often not diagnostic. There are clinical diagnostic rules for assessing which patients with dementia should undergo neuroimaging but they are not precise enough to ensure that patients with potentially reversible lesions are not missed16 . The cost-effectiveness of routine imaging in patients with suspected dementias has been questioned but with the likelihood of more effective treatments emerging in the future the situation may change. Guidelines concerning the indications for neuroimaging are available from the National Institute for Health and Clinical Excellence14 , the Scottish Intercollegiate Guidelines Network17 and the American Psychiatric Association (APA)18 . NICE recommends MRI scanning as the preferred modality to assist early diagnosis and detect subcortical (vascular) white matter changes. The APA recommends neuroimaging in cases with subacute onset (less than one year), symptom onset before age 65, vascular risk factors suggesting a higher likelihood of cerebrovascular contributory factors or a history or neurological examination findings suggesting a possible focal lesion. The usefulness of neuroimaging in late stage disease has not been established18 . CT is widely available and may be acceptable for anxious/disturbed patients. In one study19 of 178 CT scans carried out, only 4 cases of potentially reversible neurological conditions were identified and in no case did this knowledge change treatment. On the other hand 32.8% had evidence of ischaemic white matter disease. As CT is not as sensitive as MRI (see below) in detecting this, when unequivocally reported on CT scanning such ischaemic changes (‘leukoaraiosis’) support a diagnosis of mixed type dementia. MRI provides more detail of brain structure and function. As the patient must remain motionless in a tunnel for up to 20 minutes, MRI
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is not suitable for anxious or claustrophobic patients nor for those with metallic implants (pacemakers, aneurysm clips). There are few diagnostic signs relevant to psychiatry with MRI. An exception is the pulvinar sign in variant Creutzfeldt–Jakob disease (CJD), which has been found to be highly accurate and may obviate the need for more invasive testing20 . More usual is the frequent finding on MRI of white matter hyperintensities, which are commonly interpreted as evidence of small vessel ischaemia but are of uncertain diagnostic significance unless graded as severe. Positron emission tomography (PET) and single photon emission computed tomography (SPECT) utilize radioactive isotopes to assess brain metabolism (PET) and perfusion (SPECT) and provide information about the functional status of brain tissue. These investigations are discussed in detail elsewhere. Although clinical criteria may be more sensitive than SPECT, the latter is more specific in differentiating different types of dementia21 and so is recommended to aid in the differential in cases of doubt17 . Functional imaging of the dopamine transporter to assess the integrity of the nigrostriatal dopaminergic pathways is the basis of the DAT scan. DAT scanning can be helpful in distinguishing drug-induced Parkinsonism from idiopathic Parkinson’s disease and in the diagnosis of Lewy body dementia. In the latter, low striatal DAT occurs whereas DAT activity is normal in Alzheimer’s22 . The development of additional imaging tools such as quantitative MRI, functional MRI, investigational PET compounds, and other methods aimed at imaging senile plaques in the brain may help improved diagnosis, early recognition, and more precise assessment of disease progression in the future.
ELECTROCARDIOGRAPHY (ECG) The main use of ECG in psychiatry is to monitor serious cardiac side effects of psychotropic medication (Table 23.3). It is ordered in atrisk populations, e.g. those with pre-existing cardiac abnormalities or
Table 23.3 Summary of common cardiac effects of psychotropics ECG parameter
Drug
Effect
Heart rate
Clozapine; drugs with antimuscarinic side effects: TCAs, MAOIs
Heart rate variability Cardiac conduction
Clozapine Tricyclic antidepressants
Sinus tachycardia; clinicians should suspect myocarditis/cardiomyopathy in patients on clozapine if patients have fever or other cardiac symptoms such as persistent tachycardia Reduced variability associated with increased risk of cardiac death Prolong QRS complex; such changes in a patient with pre-existing conduction defect can cause complete heart block; in toxic doses (overdose) this can prove fatal Can prolong QTc interval At-risk patients can develop torsades de pointes and fatal ventricular arrhythmia Some antipsychotics may cause atrial fibrillation, heart block, changes to P and T waves May affect T waves and rarely cause heart block Torsades de pointes, ventricular arrhythmias and sudden cardiac death have all been reported; monitoring mandatory for at-risk population (pre-existing cardiac disease, high-dose antipsychotic use, overdoses especially TCAs and those with metabolic/electrolyte abnormalities) Can cause bradycardia, atrial arrhythmias; angina, syncope
Antipsychotics Haloperidol in high doses Any intravenous antipsychotic
Cardiac rhythm
Lithium All drugs that have an effect on cardiac conduction
Cardiac conduction and rhythm
Acetylcholinesterase inhibitors
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conduction defects, those on other drugs that have an effect on cardiac conduction (antiarrhythmics), those with or at risk of metabolic abnormalities (anorexia, renal failure) and patients who have taken an overdose. An ECG should be performed prior to the commencement of a tricyclic antidepressant or a cholinesterase inhibitor. Patients on high-dose antipsychotics are at increased risk of arrhythmias and sudden cardiac death, and hence ECG monitoring in this group of patients is mandatory23,24 . Lithium can change the morphology of T waves and in rare instances has been associated with heart block (Table 23.3).
Abnormality correlates with the amount of damage in the underlying brain structure, often with focal or asymmetrical changes. EEG findings of pseudo-periodic sharp wave activity (triphasic) are found in 70% of cases of CJD. Quantitative EEG (qEEG) uses a computerized programme to statistically analyse EEG recordings and may assist in diagnosis. A literature review26 suggests that abnormalities in qEEG tend to increase with the severity of the dementia. Studies have reported a moderate to high accuracy of differentiating EEG recordings in normal ageing populations and patients with dementia.
ELECTROENCEPHALOGRAPHY (EEG)
PSYCHOTROPIC DRUG MONITORING
The EEG is no longer widely used in assessment of patients in old age psychiatry and has been largely superseded by structural neuroimaging. However, in some cases the EEG can provide valuable additional information, e.g. in differential diagnosis of rapidly progressive dementia, episodic neurological symptoms and signs, or complex presentations with inconsistencies in the clinical picture and investigations. The EEG in patients with Alzheimer’s dementia may show nonspecific abnormalities even in the early stages of the disease. In frontotemporal dementia the EEG remains unremarkable until late in the disorder. Although not routinely recommended. The EEG can be highly specific (although not sensitive) in cases of sporadic CJD17 , in which case a lumbar puncture to assess for the presence of protein 14-3-3 may help with the diagnosis. The role of MRI in CJD has been discussed. Patients with dementia of Lewy body type show a characteristic early slowing of dominant EEG rhythm and 50% show focal delta wave activity in temporal regions25 . The EEG in patients with vascular dementia is more likely to be normal in the early stages.
Therapeutic drug monitoring is primarily used for drugs with a narrow therapeutic index or which show high inter-patient pharmacokinetic variability27 . Drug monitoring is mandatory for some drugs that are toxic in higher concentrations such as lithium. Monitoring can also help confirm treatment adherence. Serum monitoring was useful for tricyclic antidepressants where there was known to be a therapeutic window but with the newer antidepressants, where effective doses are close to starting doses, the need has disappeared. Most drug levels are measured when they reach steady state concentration; this takes four to five drug half-lives28 . Also sample collection should be made within 1–2 hours of the recommended time (trough or pre-dose and 12-hour post-dose, as with lithium). Mood stabilizers are one of the most commonly monitored classes of psychotropic drug (Table 23.4), although lithium is the most important because of its narrow therapeutic-to-toxic ratio. Blood levels of valproate and carbamazepine do not necessarily relate to clinical effectiveness. For clozapine, a number of patient factors have been identified that influence the serum levels. These include the age of the patient,
Table 23.4 Serum monitoring of mood stabilizers Drug Lithium
Investigations prior to prescribing Renal function
Valproate
Electrolytes ECG Thyroid function Blood glucose (preferably fasting) Liver enzymes
Carbamazepine
Full blood count ECG (if history or clinical condition suggests) Liver enzymes
Full blood count ECG (if history or clinical condition suggests)
Side effects
Average daily dosages
Target serum levels
400 mg (slow release)
0.6–0.8 mEq/l
Sedation, nausea, unsteadiness, tremor, weight gain
500–1500 mg
65–90 µg/ml (not definitely established)
Sedation, ataxia, nystagmus, blurred vision, agranulocytosis, hyponatraemia
400–800 mg
4–12 µg/l (levels for epilepsy)
Polyuria, gastrointestinal upset, tremor, neurological disturbance (toxicity), weight gain, oedema, psoriatic rash
DIAGNOSIS AND ASSESSMENT ethnicity, smoking status and interactions with other drugs. Plasma levels of 350–500 µg/l have been suggested for optimal clinical response. Seizures have been identified to be commoner in patients with levels higher than 1000 µg/l29 . Some authors have suggested the prophylactic use of valproate to prevent seizures when the plasma levels are >600 µg/l.
OTHER INVESTIGATIONS Cerebrospinal Fluid Analysis Lumbar puncture (LP) is generally performed under the care of physicians or neurologists with the main indications being confirmation of CNS infections (bacterial, tubercular, fungal), inflammatory conditions (vasculitis) or malignancy. With the developments in neuroimaging, many of these conditions can be identified on scans. The role of LP in suspected CJD can be diagnostic and has been discussed.
Sleep Studies Common sleep complaints include insomnia, excessive daytime sleepiness and parasomnias such as REM sleep behaviour disorder (SBD), as seen in dementia with Lewy bodies. Other conditions that may be misdiagnosed as primary psychiatric illnesses include narcolepsy and sleep apnoea syndrome. The latter is increasingly recognized as a cause of or contributory factor to confusional states. Primarily the assessment of sleep-related disorders relies on clinical evaluation and sleep charts. Polysomnography is available in specialist centres and involves measurement and observation of different stages/components of sleep along with recordings of EEG, electro-oculogram and electromyogram. Sleep apnoea is diagnosed with simultaneous monitoring of respiratory effort and oxygen saturation overnight and is offered by respiratory medicine departments.
Genetic Studies Genetic screening and prediction of risk raises many ethical dilemmas. However, old age psychiatrists increasingly see younger patients with dementia for whom genetic considerations apply and they should know when to refer to a colleague specializing in psychiatric genetics. Ethical issues of confidentiality and information sharing pose a great challenge to clinicians and geneticists. The experience may be emotionally challenging to patients and the results may not be conclusive. Issues of ‘the right not to know’ and implications for the individual’s future employment and discrimination in access to insurance policies need to be considered. Some tests can result in stigmatization and unwarranted anxiety among family members. Genetic testing is predictive for only some conditions. Alzheimer’s disease has been associated with mutations in amyloid precursor protein (APP) and presenilin 1 and 2 genes. Frontotemporal dementia studies have suggested mutations in tau protein (in some families involving autosomal dominance) and α-synuclein has been recognized in Parkinson’s disease. Early onset (<65 years) Alzheimer’s disease is associated with gene mutations that are transmitted in an autosomal dominant fashion. While late onset Alzheimer’s disease (>65 years) is generally considered to be idiopathic or sporadic, numerous studies have shown increased risk of developing the disease (odds ratio between 3 and 15) in individuals with APO E4 allele on chromosome 1930 .
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However, testing for apolipoprotein E4 (APOE4 ) is not recommended for use in the diagnosis of dementia31 . Commercial kits are available for testing certain genes, for example presenilin 1 (PSEN1 ) on chromosome 14 but careful interpretation is required and should only be undertaken in the context of pre- and post-test counselling18 . In addition, specific genetic testing is available for Huntington’s disease and CADASIL (cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy – Notch 3 gene polymorphisms). Lastly, there is current interest in the glucocerebrosidase gene in Lewy body dementia, which may in the future have implications for genetic testing32 .
LEGAL CONSIDERATIONS Always record whether the patient consents to undergoing investigations and if they are unable whether it is in their best interests to undergo them. In English law, in an emergency, the Capacity Act (2005) permits reasonable and proportionate force for necessary testing and the Mental Health Act (2007) allows the Responsible Clinician to make arrangements for testing of detained patients where this is of direct relevance to their mental disorder (this includes withdrawing blood for clozapine monitoring). It does not, however, mandate testing of an unrelated condition, e.g. an endoscopy for incidental anaemia. Colleagues responsible for carrying out the investigation must conduct their own assessment of capacity. For example, an endoscopist must be satisfied that the patient understands the procedure and if this is not clear they will often seek the advice of the psychiatrist who has referred the patient. Colleagues undertaking investigations for the psychiatric team should be forewarned if the patient lacks capacity, both for their own safety and because certain tests will be difficult to perform without collaboration of the patient. Testing of a patient for the good of others without consent is not permitted. The Human Tissue Act (2004) makes this clear. For example, this includes a member of staff who has been bitten by a patient with dementia and who may wish to know the patient’s hepatitis and AIDS status. The Capacity Act (2005) may permit testing if it can be demonstrated that such knowledge is in the patient’s interest, e.g. if it might lead to less restrictive nursing. Legal advice would still be needed regarding the disclosure of results to a third party.
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25. Briel R. EEG findings in dementia with Lewy bodies and Alzheimer’s disease. J Neurol Neurosurg Psychiatry 1999; 66: 401–3. 26. Coburn KL, Lauterbach EC, Boutros NN et al. The value of quantitative encephalography in clinical psychiatry: a report by the committee on research of the American Neuropsychiatric Association. J Neuropsychiatry Clin Neurosci 2006; 18: 460–500. 27. Hiemke C. Clinical utility of drug measurement and pharmacokinetics – therapeutic drug monitoring in psychiatry. Eur J Clin Pharmacol 2008; 64: 159–66. 28. Taylor D, Paton C, Kerwin R. Plasma level monitoring of psychotropics and anticonvulsants. In The Maudsley Prescribing Guidelines, 9th edn. London: Informa Healthcare, 2007, 1–5. 29. Greenwood-Smith C, Lubman DI, Castle DJ. Serum clozapine levels: a review of their clinical utility. J Psychopharmacol 2003; 17(2): 234–8. 30. Bertram L, Tanzi RE. The genetic epidemiology of neurodegenerative disease. J Clin Invest 2005; 115: 1449–57. 31. Knopman DS, DeKosky ST, Cummings JL et al. Practice parameter: diagnosis of dementia (an evidence-based review), report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2001; 56; 1143–53. 32. Leverenz JB, Lopez OL, DeKosky ST. The expanding role of genetics in the Lewy body diseases: the glucocerebrosidase gene. Arch Neurol 2009; 66(5): 555–6.
Internet Resources
Dementia guidelines NICE Dementia Guidelines: www.scie.org.uk/publications/misc /dementia/index.asp; http://guidance.nice.org.uk/CG42/Guidance /doc/English SIGN dementia guidelines: www.sign.ac.uk/pdf/sign86.pdf American Psychiatric Association: www.psychiatryonline.com /pracGuide/loadGuidelinePdf.aspx?file=AlzPG101007 American Academy of Neurology: www.aan.com/professionals /practice/pdfs/dementia_guideline.pdf Neurology (journal): www.neurology.org/cgi/content/full/56/9/1143
Legal and Ethical considerations Mental Capacity Act (2005): www.opsi.gov.uk/acts/acts2005/ukpga _20050009_en_1 Mental Health Act (2007): www.dh.gov.uk/en/Healthcare /Mentalhealth/index.htm Human Tissue Act (2004): www.dh.gov.uk/en/Publichealth /Scientificdevelopmentgeneticsandbioethics/Tissue /Tissuegeneralinformation/DH_4102169
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Bedside Assessment of Cognitive Functioning Richard Perry Department of Neurosciences, Imperial College and Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, UK
INTRODUCTION In the future, clinicians are likely to make ever more use of newer diagnostic techniques such as multimodal MRI imaging, PET imaging and CSF analysis. These ancillary investigations are only helpful in the appropriate clinical context in terms of their ability to discriminate between various diseases and in how their results are interpreted. As always in medicine, this clinical context comes from careful and considered history and examination.
HISTORY TAKING IN COGNITIVE ASSESSMENT One key aspect of the cognitive history is the necessity of gaining a witness or corroborative account. By their nature, cognitive impairments may include lack of insight and impaired ability to express details of the history as a result of memory, language or other cognitive deficits. It is therefore strongly recommended that a witness history is taken and it is often beneficial to perform this separately from the patient, particularly if personality or behavioural changes are to be exposed. An in-depth discussion of all aspects of the cognitive history is beyond the scope of this chapter and we have excluded the wellknown aspects of past psychiatric history, past medial history, educational and occupational history and social and family history in favour of highlighting some tips specific to cognitive history taking, which although not meant to be foolproof, nevertheless may provide helpful clues to direct the clinician.
Initial Presentation and Impressions Although not without exception, on the whole, if a spouse, friend or carer is the instigator of the referral, this is more suspicious of an underlying organic brain disorder than patients who self-present. Patients who attend a clinic alone have a much greater chance of having an underlying affective cause of their symptoms than those who are accompanied. Many patients who are ‘brought’ to a consultation adopt this role very quickly and defer to their spouse or friend in sitting down and answering questions. A common occurrence is the response to the first greeting or question – when the examiner asks why the patient has come to see them, the patient may immediately turn to their spouse for help or confirmation without actually addressing
the question. Anecdotally this reaction seems to have a fairly high specificity for underlying organic brain disease.
Presenting Complaint It is important to clarify the first symptom that has been noticed by the patient or carer. Patients presenting with moderate stages of dementia may have a multitude of symptoms that overlap between dementia subtypes and often the first symptom can be instructive regarding diagnosis. For example, memory deficits are invariably the earliest feature of Alzheimer’s disease whereas behavioural changes are invariably the initial feature of frontotemporal dementia despite both sets of symptoms being present in both conditions as they progress. It is often difficult for patients or informants to be accurate about the duration of symptoms which are usually underestimated. A little gentle probing can often extend the history from an initial estimate of six months to several years, thereby narrowing the differential diagnosis. It is useful to ask such questions as ‘how were they three years ago – were they the same as 20 years ago?’
Behavioural and Personality Changes To get a clear history of behavioural or personality change, the interviewing of an informant is critical as lack of insight often accompanies such behavioural changes. Major personality change is usually a result of pathology in the limbic, paralimbic and frontal-striatal systems. They may be seen in space occupying lesions of the frontal lobe and subcortical dementias but the condition where specific personality changes are virtually diagnostic is frontotemporal dementia. A simple question such as ‘have you noticed any changes in X’s behaviour or personality?’ is usually a helpful opening gambit. A not uncommon response in frontotemporal dementia is that ‘they are not the same person that I married’. Behaviours to probe for include apathy, passivity and lack of initiation. Indeed some patients are often content to let others discuss less than complimentary changes in their behaviour or personality without need to interject or justify themselves in any way. Disinhibited behaviour can be enquired about in terms of whether the patient has done or said anything that causes embarrassment or is inappropriate, especially in public. Rigidity in behaviour may be evidenced by strict and unnecessary time keeping or eating habits such as always eating the same food at the same time of day. Obsessive and compulsive
Principles and Practice of Geriatric Psychiatry, 3rd edn. Edited by Mohammed T. Abou-Saleh, Cornelius Katona and Anand Kumar 2011 John Wiley & Sons, Ltd
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behaviour should be questioned and the duration of this ascertained to differentiate from longstanding personality traits. Gradual loss of empathy and blunting of emotional repertoires should be sought and a change in food preferences for sweet things or the development of a catchphrase are both behavioural changes that are virtually pathognomonic of frontotemporal dementia.
Autobiographical History It is useful to go through details of schooling and major life events in early adulthood, primarily to see if the subject has impaired autobiographical memory. An inability to remember where they went to school, when they were married and where, or what their first job was, is concerning for an organic dementia as these memory abilities are not usually affected in psychiatric disorders.
Medications Elderly populations may have a multitude of medical and psychiatric co-morbidities and hence multiple medications, many of which may affect cognition. Particular medications to note are opiate-based analgesics such as codeine or tramadol, medications with anticholinergic properties such as tricyclic antidepressants, antispasmodics, anti-emetics, anti-parkinsonian medication, bronchodilators, or antiarrhythmics.
Activities of Daily Living Ask about performance at work if appropriate, ability to travel to new locations alone, handling of finances and bank accounts, social events, use of household devices including telephones, TVs etc., preparation of meals, organizing of family events such as trips and holidays. A gradual change of responsibilities from patient to spouse or other carer over several years is revealing.
BEDSIDE COGNITIVE ASSESSMENT Initial Observations The bedside cognitive assessment starts with observation of the patient. Watch how the patient enters into the consultation room, paying particular attention to their gait and observe how they sit down in a chair. The gait abnormality of idiopathic Parkinson’s disease is easy to recognize if one is watching for it. Slow and shuffling with short steps, narrow base, stooped posture with decreased arm swing. It is surprising how often this is overlooked. If a diagnosis can be made before the patient has sat down, it is very helpful for the rest of the consultation! The gait of cerebrovascular disease is characterized by the sense that the feet are rooted to the ground with a more wide-based gait, again with small steps. The gait of normal pressure hydrocephalus is usually more wide-based than that of cerebrovascular disease and is unsteady with less adherence of the feet to the floor. Further useful information can be taken from watching the patient sit in a chair – difficulty in orienting to the chair or sitting on the edge or armrest of a chair by mistake suggests significant apraxia. If a patient falls back heavily into a chair, be on the lookout for additional signs of progressive supranuclear palsy. Throughout a cognitive assessment it is useful to keep the question in mind of whether one is dealing with a predominantly cortical or subcortical picture of impairment. The cardinal features of
a subcortical cognitive impairment are slowing of thought, response and movement with impaired attention. The major cortical deficits to look out for are language impairment (aphasia), visuospatial impairment and praxis and so the finding of one of these deficits suggests cortical involvement (note the rare exceptions of aphasia from basal ganglia lesions). Memory deficits may be present in both cortical and subcortical syndromes. Another important question to return to during the consultation is whether the patient has an organic or psychiatric origin to their symptoms. Although it is not always possible to be certain, there are certain clues from both the history and examination that may guide the examiner. Symptoms that are fluctuating or specific to either the home or workplace are suspicious for psychiatric symptoms, as are symptoms that are noticed solely by the patient rather than others. In the examination, psychiatric syndromes may often manifest with impaired memory, executive functions and processing speed deficits but the presence of real language deficits, apraxia or visuospatial function is far more concerning for organic brain disease.
Cognitive Rating Scales The most widely used screening tool for bedside cognitive assessment is the Mini Mental State Examination (MMSE) which typically takes 8–10 minutes to administer and assesses orientation, memory, language and visuospatial function and is scored out of 30 points. As the MMSE is the subject of a separate chapter (see Chapter 27), it will not be described in detail here, but it is worth considering a few of its major advantages and disadvantages. Advantages:
• ease of administration; • wide use helps comparison of scores across patients and testing centres;
• suitable for longitudinal assessment; • quick. Disadvantages
• does not assess speed of information processing or executive function;
• minimal assessment of memory; • ceiling effect in mild cognitive impairment and frontotemporal dementia;
• test–retest reliability (intra-rater) of +/− 3; • inter-rater reliability suspect on serial 7s and ‘world’ backwards. Because of these limitations, which are likely to be inherent in any short screening tool, various adaptations of the MMSE have been devised. The most promising of these is the Addenbrooke’s Cognitive Examination (ACE) which includes all of the subtests of the MMSE but is expanded to include more detailed tests that provide scores for each of the five domains of episodic memory, verbal fluency, naming, language and visuospatial function. The latest revised version, the ACE-R, comes on six pages of A4, takes approximately 20 minutes to administer and is scored out of a total of 100. The full ACE-R with administration and scoring guidelines is available on line at http://pn.bmj.com/supplemental. The memory domain includes a seven-item name-and-address test in which the patient is asked to register a name and address (e.g. Simon Williams, 17 Somerfield Road, Croydon, Surrey) across three learning trials and then recall after a 10-minute delay. There are
DIAGNOSIS AND ASSESSMENT two tests of verbal fluency. In letter fluency, the patient is asked to produce as many words beginning with ‘p’ as possible in one minute and in category fluency, as many animals as possible. The naming section is far more sensitive than that on the MMSE and consists of 10 line drawings of low-frequency items. The authors of the ACE-R have carried out validation studies suggesting two cut-off scores of 88/100 or 82/100 for clinical practice. In the initial publication the upper cut-off score of 88 has a good sensitivity for dementia of 94% and a specificity of 89%1 . This high sensitivity was reproduced in a later study although specificity was considerably lower with many false positives2 . The specificity of the ACE for dementia is increased at the lower cut-off score of 82 without a major loss of sensitivity. Proponents of the ACE have examined its potential to differentiate between dementia subtypes. The initial reports used a ratio of the domain scores of verbal fluency + language/orientation + memory (VLOM ratio) to differentiate between Alzheimer’s disease and frontotemporal dementia and found that a ratio >3.2 supports Alzheimer’s disease whereas a ratio of <2.2 is in favour of frontotemporal dementia1 . Follow-up studies have confirmed the ratio of >3.2 as being reasonably sensitive and specific for AD although the sensitivity of a ratio of <2.2 for frontotemporal dementia is probably too low for clinical utility, especially when such studies do not take into account the pre-test probability of a diagnosis2 . In clinical practice a diagnosis is not based on the ACE alone but in combination with the history, examination findings and imaging investigations. A more recent study has attempted to use the ACE in conjunction with episodic memory tests such as the Rey Auditory Verbal Memory Test and the CANTAB Paired Associates Learning to identify MCI cases at greatest risk of conversion to Alzheimer’s disease3 . There was reasonable evidence that the combination of a broad screening tool of multiple cognitive domains such as the ACE plus two or more episodic memory tasks was effective in terms of both positive and negative predictive value. Indeed it is likely that this combination, which could be performed in a clinical assessment, is almost as effective as a more formal and extended neuropsychological assessment. In the author’s own practice, the subtests that appear to be the most helpful in adding to the MMSE to aid differential diagnosis are the episodic memory task, the verbal fluency task and the naming task. If the ACE were to be improved upon, it would be to further develop the episodic memory task to a word-list learning task with trials of registration and delayed recall. In clinical practice we are often trying to reliably identify which patients have impaired episodic memory that may be the earliest stages of Alzheimer’s disease and the current name-and-address task may be too insensitive to fulfil this role, particularly in patients who have been cognitively high performing. Despite this limitation, the ACE is already becoming more widely used and appears to be an easily administered and helpful tool in the memory clinic.
Assessing Different Cognitive Domains Orientation to time usually includes an assessment of day, month and year. In general, orientation to time is lost before orientation to space and this is particularly true of Alzheimer’s disease. Not knowing the date is not specific and indeed many normal subjects are unaware of the date. Usually when testing date with the MMSE a margin of +/− two days is given. It is notable that disorientation to person in the absence of obtundation of conscious level is suspicious of factitious disorder. The catch is with severely and suddenly aphasic patients
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who can present to the unwary as confused and even as functional in origin. Attention can be tested at the bedside with the serials 7s or ‘world’ backwards of the MMSE or ACE. Memory. The history informs us about autobiographical memory and further assessment can probe for deficits in episodic, working or semantic memory. Working memory refers to information that is kept ‘online’ and in constant rehearsal for periods of up to around 30 seconds. It can be disrupted by interference and memories are not actually laid down for later recall. At the bedside this can be tested by forward and backward digit spans: In forward-digit span, a series of numbers, usually starting with three (e.g. 492) is read to the subject evenly at one integer every second who then repeats the numbers back. The digit span is taken as the maximum number of digits repeated back until two successive failures at a string length have occurred. The normal range is 6 +/− 1. Backward-digit span is performed in the same way except that the subject is asked to repeat the string of numbers backwards (e.g. examiner reads 947, subject repeats 749). The normal range is 5 +/− 1. Episodic memory refers to memory for events that have been personally experienced. It has two main components: anterograde memory (new learning) and retrograde memory (memory for past events). The functional neuroanatomy of episodic memory involves the limbic-diencephalic system and its frontal connections and most importantly the hippocampal complex. Patients with disorders of episodic memory will present with forgetfulness for recent events, have difficulty keeping to the plot of novels or even films, may forget messages and rely on lists and may be repetitive. Assessment of retrograde memory is predominantly from the history including the autobiographical history (see above) and specific questions related to more recent events such as details of holidays over the last year or two, details of family events such as weddings or Christmas and knowledge of recent major news events. Anterograde memory can be assessed at the bedside and clinicians often use the memory subtests of the MMSE although the seven-item name-and-address task of the ACE is more sensitive. A patient’s previous level of performance should be taken into account and even recall of all seven items may be obtained in those high functioning but in the earliest stages of a degenerative disease. Semantic memory refers to our memory for facts, word meanings and general knowledge. The neural substrate that appears to be important for semantic memory is the cortical area of the anterior/inferior temporal lobe. Deficits can be apparent from the history by ‘empty speech’ with circumlocutions. Speech content is diminished and words are replaced with generics such as ‘things’. Bedside assessment can be with verbal fluency tests, naming of objects or line drawings, tests of verbal knowledge and reading of regular or irregular words. Verbal fluency, as used in the ACE, can test both phonemic fluency (words beginning with ‘p’, ‘d’, ‘f’ etc.) in a minute or with semantic fluency (e.g. animals, tools, fruits etc.). In conditions characterized by semantic memory impairment there tends to be a discrepancy between semantic and phonemic fluency whereas predominant impairment of phonemic fluency is typical of subcortical syndromes such as cerebrovascular disease, parkinsonism, or depression4,5 . Tests of semantic knowledge in the verbal domain include questions such as: what colour is grass? where do elephants live? which animal has four legs, a hump and lives in deserts? The ACE language subtests probe for impairment in the reading of irregular words, a difficulty which is often associated with semantic memory impairment. In this context, patients may have difficulty in
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reading irregular words such as height or yacht and when asked to read ‘mint’, ‘pint’ and then ‘rint’ may read ‘rint’ as in ‘pint’. If significant and disproportionate semantic impairment is suspected, further assessment of knowledge about famous people or famous faces can be helpful. Right temporal lobe atrophy and involvement of the fusiform gyrus as seen in the right temporal variant of frontotemporal dementia seems to be particularly associated with face recognition and knowledge impairments6 . This is one of the only uses the author has found for publications such as celebrity magazines! Language. It is important to differentiate actual language disorders (aphasias) from dysarthria which refers to the impairment of the mechanical aspects of sound production. From the history, the examiner will be able to gather important information about spoken language such as its degree of fluency, whether there are any articulatory problems, difficulties with word finding, impairment of intonation, rhythm or musicality (dysprosodia), or paraphasic errors. When assessing fluency, the most important issue will be whether the person is able to produce language effortlessly or not, regardless of the actual content. Non-fluent speech is effortful and halting with reduced sentence length, agrammatism and impaired prosody where the normal rhythms and undulations of speech are affected. Phonemic paraphasias may be detected where the sounds within words are incorrect, e.g. incollect rather than incorrect. Where the speech deficits are characterized by slow speech, increased pauses between words and distorted sounds but without phonemic problems, the term apraxia of speech may be used. Fluent speech is characterized by lack of effort and normal articulation but with lack of content and circumlocutions. After listening to speech output a simple assessment of comprehension is valuable using simple instructions in a graded manner. It is helpful to start with one-stage commands such as ‘close your eyes’ before more complicated commands such as ‘lift up your left hand and then stick out your tongue’ or ‘after touching the desk, touch your left ear with your left hand’ Repetition is likewise tested in a graded manner starting with simple words such as ‘toaster’ before more complicated and polysyllabic words such as ‘accordion’ or ‘catastrophe’ and then on to short sentences such as ‘The orchestra played and the audience applauded’ as in the Cambridge ACE. Watch for phonemic paraphasias as described above and whether these are consistent mistakes. Naming is tested by asking the patient to name particular objects or line drawings. There is a frequency effect in which commonly used words are less affected than uncommon words. For example, patients might be able to name high-frequency objects such as ‘pen’ and ‘watch’ (MMSE), but may have problems with more low frequency ones such as ‘anchor’ or ‘barrel’. Reading and its testing at the bedside is influenced by educational factors which need to be taken into account. An in-depth assessment of reading is not frequently required unless the history and general cognitive screen (e.g. ‘close your eyes’ from the MMSE) identifies specific problems in this area. The Cambridge ACE is a suitable screening tool as it includes regular and non-regular words which can help determine the presence of a surface dyslexia. This form of dyslexia is typical of semantic memory impairment, possibly because these words require semantic knowledge of the word in order to read it, unlike regular words or non-words which can be read without understanding the meaning of the word. Like reading, writing may not require a detailed assessment unless there are specific symptoms or a fairly circumscribed language deficit is suspected. In these situations, assessment of written spelling and sometimes writing of individual letters is required.
Calculation. A few simple tests of calculation can be extremely useful in a bedside assessment, especially in the situation of progressive aphasia where the clinician wish to differentiate between a perisylvian or frontal opercular syndrome. This cognitive function is highly susceptible to the person’s previous arithmetic ability, which will have to be taken into consideration in order to interpret the findings but a few simple examples of mental arithmetic will usually suffice. Visuospatial function. These can be easily assessed at the bedside by asking patients to copy simple line drawings such as the intersecting pentagons from the MMSE or the cube or clock face from the ACE. If there is disproportionate visuospatial impairment further analysis should include examination for features of Balint’s syndrome. Although it often presents in a partial or impure state, it classically has several components, the most striking of which is simultanagnosia, which refers to the inability to widen a visual focus and synthesize a wider scene. Often described as a narrowed spotlight of attention, subjects may report only one part of a scene and ignore the wider picture. This can be picked up at the bedside by dot counting (as in the ACE) or in describing visual scenes from magazine photographs. The other features of Balint’s syndrome include optic ataxia, which is the inability to accurately reach for objects in the absence of limb ataxia and optic apraxia or sticky fixation which is the inability to move the eyes to a target. The neural substrates of Balint’s syndrome are invariably bilateral damage to the parietooccipital cortex which may result from watershed infarcts or from neurodegenerative conditions such as the posterior cortical atrophy variant of Alzheimer’s disease. Praxis is typically defined as the inability to perform skilled motor movements in the absence of any deficit of power or sensation. Although usually associated with lesions in the left parietal lobe, apraxia may also be seen after lesions to the right parietal lobe, frontal lobes and subcortical structures in the basal ganglia. The description of many subtypes of apraxia such as ideational or ideomotor apraxia has led to considerable confusion due to the inconsistency with which different terms are used by different investigators but in practice such differentiations rarely help in differential diagnosis. The most important aspect of bedside assessment is to demonstrate impaired praxis, which, like visuospatial impairment, is rarely seen in purely psychiatric disorders. This can usually be achieved by asking the patient to copy a series of hand gestures, e.g. ‘hitchhiking sign’, or by asking them to mimic the use of objects e.g. ‘show me how you brush your teeth’ or ‘show me how you comb your hair’. The presence of impairment in praxis usually suggests organic cortical dysfunction. Executive function refers to those higher order cognitive capabilities that are called upon to formulate new plans of action and to select, schedule and monitor appropriate sequences of action. A lot of these functions are mediated by the dorsolateral prefrontal cortex and the subserving fronto-subcortical circuit. However, other aspects of the prefrontal cortex are also involved in some of these functions, such as the inferior frontal areas, in abilities that relate to impulse control and inhibition. Although best tested with formal neuropsychological measures, some assessment is possible at the bedside. Verbal fluency, as described above and assessed in the ACE, is invariably impaired in dysexecutive syndromes, particularly phonemic or letter fluency. Studies show that 15 items in one minute represents a normal performance. Less than 10 items is definitely abnormal. Marked and particular impairment in letter fluency is a hallmark of subcortical disorders. Another bedside task of executive function is cognitive estimates where a subject is asked to make an educated guess to a
DIAGNOSIS AND ASSESSMENT question to which they are not expected to know the exact answer. Examples include ‘how many people live in London?’, ‘how fast can a horse run?’, or ‘how many camels are there in Holland?’. Patients with marked executive impairment tend to give answers that are completely off the mark such as 3000 people living in London. Proverb interpretation, e.g. ‘what is the meaning of the phrase ‘people in glass houses shouldn’t throw stones’?’ can be helpful although a patient’s age and cultural background may affect their knowledge of such proverbs. A particular aspect of executive function called response inhibition can be tested with the go-no-go test. In this test the examiner asks the subject to place a finger on the desk. The examiner can then tap with their own finger under the desk either once or twice. The subject is instructed to tap once when the examiner taps twice and to tap twice when the examiner taps once. The examiner then begins a series of taps, either once or twice and switches between the two stimuli. Normal subjects pick up the rules to this quickly and can switch without perseverating in their responses. It is important to remember that executive functions and ‘frontal lobe’ functions are not synonymous. Executive impairment can manifest from brain injury outside the frontal lobes. A case in point is the cerebellar affective syndrome where cerebellar injuries produce a range of behavioural and neuropsychological deficits very like those seen in frontal lobe syndromes.
The Neurological Examination in Bedside Cognitive Assessment Specific neurological signs often accompany cognitive and neurobehavioural disorders and although a full discussion of the relevant neurological examination techniques is outside the scope of this chapter, there are some specific systems that should be examined. These should be taken in the context of the observations made of the patient throughout the consultation regarding speed of movement and thought, speech and other motor deficits. Eye movements. In the context of the bedside cognitive assessment the most important aspects of the eye movements are to look for evidence of cerebellar dysfunction or of supranuclear gaze palsy. Probably the most sensitive measure of dysfunction of the cerebellar system and its connection to the brainstem is the examination of eye movements and nystagmus should be observed for in lateral gaze, upgaze and downgaze. Pursuit movements refer to the smooth tracking of a target from one side to the other and saccadic movements refer to the rapid movement of the eyes from one target to another. All of these eye movements may be affected in cerebellar disease. Evidence of impairment of supranuclear gaze can be sought by asking the patient to look up to a target and then down while the examiner gently holds the head still. Restriction of upgaze is common with age and is a non-specific marker for extrapyramidal degenerative syndromes. Impairment of downward saccades, particularly slowed downward saccades may support a suspicion of PSP in the right clinical context. Extrapyramidal signs The cardinal extrapyramidal signs are bradykinesia, rigidity and involuntary movements such as tremor or chorea. Bradykinesia refers to a gradual decrease in speed of movements with repetition and can be elicited in repetitive hand movements or foot tapping. Limb rigidity is suggestive of parkinsonism and axial rigidity, particularly when accompanied by a history of falls and a supranuclear gaze palsy is suggestive of PSP. The tremor of Parkinson’s disease is usually, but not always, more prominent at rest and increases with distraction. Lower limb tremor,
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particularly unilateral, is very suggestive of Parkinson’s disease. Chorea is usually seen as restless flowing involuntary movements, which if mild may just give the impression of a patient being fidgety and should prompt for further exploration of a family history consistent with Huntington’s disease and previous psychoactive drug use. Myoclonus refers to intermittent sudden jerks, usually of the limbs and may be stimulus sensitive. Provocation of stimulus sensitive myoclonus may be with a loud clap out of the patient’s field of vision. Alternatively upward flicking movements on the underside of fingers of outstretched hands may elicit myoclonic jerks of the same or even contralateral limb. While myoclonus may be present in many neurodegenerative diseases such as Alzheimer’s disease, dementia with Lewy bodies and corticobasal degeneration, it is most commonly associated with prion diseases such as Creutzfeldt-Jacob disease, particularly in the presence of a rapidly progressive dementia. Primitive reflexes. These reflexes are present in newborn babies and tend to disappear with brain maturation. Their re-emergence in adult life suggests disconnection of the fronto-striatal circuits and hence brain pathology. The grasp reflex refers to the involuntary gripping of the examiner’s hand when this stimulates the patient’s palm. The examiner must tell the patient to let go off the hand. Often attempted withdrawal of the examiner’s hand leads to more pronounced grasping. The pout reflex is elicited by putting an orange stick vertically onto the closed lips of the patient and tapping. Other primitive reflexes such as the glabellar tap or palmomental reflex seem to have less discriminatory value.
CONCLUSIONS As with all aspects of clinical medicine the history is paramount and should be used to guide the clinician to an initial differential diagnosis that can be refined with the examination. While further diagnostic tests are often necessary after bedside assessment, these are most directed and informative if based on a sound clinical assessment. During this process it is helpful for the clinician to keep in mind a few cardinal questions that can be answered along the way. What were the first presenting symptoms and how long ago did they really start? How is the patient moving and can this help me? Have I got a reliable witness history? Is the presentation psychiatric or organic? Is the pattern cortical or subcortical and what cognitive domains are involved? By reference back and forth to these questions during the assessment the clinician can interpret the pattern of deficits of a simple cognitive screening tool such as the MMSE or ACE and add refinements to the examination to probe different cognitive functions in more detail. This should lead to a formulation of ‘where’ the problem lies in terms of the functional neuroanatomy of the brain, which when considered in the light of the onset and progression of the symptoms, can guide towards an accurate differential diagnosis.
REFERENCES 1. Mathuranath PS, Nestor PJ, Berrios GE, Rakowicz W, Hodges JR. A brief cognitive test battery to differentiate Alzheimer’s disease and frontotemporal dementia. Neurology 2000 December 12; 55(11): 1613–20. 2. Larner AJ. Addenbrooke’s Cognitive Examination (ACE) for the diagnosis and differential diagnosis of dementia. Clin Neurol Neurosurg 2007 July; 109(6): 491–4.
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3. Mitchell J, Arnold R, Dawson K, Nestor PJ, Hodges JR. Outcome in subgroups of mild cognitive impairment (MCI) is highly predictable using a simple algorithm. J Neurol 2009 September; 256(9): 1500–9. 4. Steffens DC, Otey E, Alexopoulos GS, Butters MA, Cuthbert B, Ganguli M et al . Perspectives on depression, mild cognitive impairment, and cognitive decline. Arch Gen Psychiatry 2006 February; 63(2): 130–8. 5. Potter GG, Steffens DC. Contribution of depression to cognitive impairment and dementia in older adults. Neurologist 2007 May; 13(3): 105–17. 6. Chan D, Anderson V, Pijnenburg Y, Whitwell J, Barnes J, Scahill R et al . The clinical profile of right temporal lobe atrophy. Brain 2009 May; 132(Pt 5): 1287–98.
FURTHER READING Ancelin ML, Artero S, Portet F et al. Non-degenerative mild cognitive impairment in elderly people and use of anticholinergic drugs: longitudinal cohort study. BMJ 2006; 332: 455–9.
Bak TH, Mioshi E. A bedside cognitive assessment beyond the MMSE: the Addenbrooke’s Cognitive Examination. Prac Neurol 2007; 7, 245–9. Bonelli RM, Cummings JL. Frontal-subcortical dementias. Neurologist 2008; 14: 100–7. Hodges JR. Cognitive Assessment for Clinicians. Oxford: Oxford University Press, 1994. Hodges JR, Patterson K. Semantic dementia: a unique clinicopathological syndrome. Lancet Neurol 2007; 6: 1004–14. Schott JM, Rossor MN. The grasp and other primitive reflexes. J Neurol Neurosurg Psychiatry 2003; 74: 558–60.
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Neuropsychological Assessment Linda Clare School of Psychology, Bangor University, Bangor, Gwynedd, UK
Neuropsychological assessment offers a rigorous method of identifying the presence, extent and severity of cognitive impairments. Brief observation and informal interaction can yield valuable information about a patient’s condition, but this level of assessment does not usually provide a sufficient foundation for evaluating the degree or extent of cognitive difficulties, and may mean that subtle or mild difficulties are missed. Therefore, a more systematic approach to assessing patients’ cognitive functioning is often needed. Neuropsychological assessment achieves this aim through the use of standardized tests.
THE USE OF STANDARDIZED TESTS Standardized tests assess aspects of current functioning in a systematic way, providing results that can be compared with normative data1 . They are developed with the aim of maximizing reliability and validity; that is, they should provide a consistent measure of the construct of interest. Standardized tests are always administered in the same way, following administration procedures set out in the test manual. Thus, the instructions given to each person taking the test, and all the parameters of the test such as the length of time for which stimuli are presented, are identical. These conditions are exactly the same as those used to obtain data from the reference group or normative sample against which the individual’s test scores will be compared, ensuring a valid comparison. Norms typically take into account the effects of age, providing stratified norms for different age groups, and adjustment may be made for other demographic factors that affect test performance, such as level of education. It follows that familiarity with the test procedures is essential in order to administer the test appropriately. Similarly, familiarity with the scientific basis and technical properties of the test, as well as the ability to consider the complex range of factors that may impact on test performance, is necessary for accurate interpretation of test results. For this reason, use of many standardized tests is restricted to those professionals who can demonstrate either by virtue of their professional education or as a result of further training that they are specifically trained in test administration and interpretation. Neuropsychological assessment of older people combines two traditions of standardized testing: psychometric testing and clinical neuropsychological assessment. These two approaches have been described as population-based and deficit-oriented , respectively2 . In practice, the two approaches are typically used alongside one another, with an emphasis on considering patterns of scores across a range of tasks.
Psychometric testing assumes that the ability or factor being tested is normally distributed in the general population, and seeks to establish how the individual’s scores relate to those found in a representative sample of that population; for example, whether scores are close to the average for the reference group, or whether they are exceptionally high or low, and thus unusual. The classic example of this would be the measurement of IQ. Standardized tests of this kind typically include items across the range of difficulty, such that there will be some easy items that just about everyone should be able to do and some very challenging items that hardly anyone will be able to answer. Some tests identify different starting and finishing points for different age groups so that a range of items of appropriate levels of difficulty is administered, and some tests have rules specifying that the task should be discontinued in the event of incorrect answers being given on a specified number of items, on the basis that further, more difficult items would not be expected to be answered correctly. Therefore, these tests are suitable for individuals across the ability range and provide a challenging test for even those individuals with the highest levels of ability. Clinical neuropsychological assessment sets out to determine whether there is evidence of impairment in a particular ability, such that the individual’s scores are different to what they would have been if illness or injury had not intervened. This may be determined by comparing performance on abilities thought to be affected by the illness or injury with performance in areas thought to remain intact, or may be inferred from a comparison of the individual’s scores with scores obtained by a normative sample, taking into account what would be expected on the basis of the individual’s background. In the latter case, normative data will typically have been used to identify a cut-off score, signifying that scores more extreme than this value are unlikely to occur within the normal range. Standardized tests based on this approach rest on the assumption that the normal population will generally perform well and that poor scores are indicative of neurological abnormality. Scores on standardized tests may be expressed in a number of ways. Most frequently, raw scores are typically converted to either a standard score or percentile rank, allowing comparison across subtests and against norms. The standard scores corresponding to given raw scores on a test are calculated on the basis of normative data collected from a large sample, taking into account the distribution of scores in the sample and the mean level of achievement. Where age is likely to affect performance, the standard scores derived from the raw scores are compared to norms for the relevant age group. The
Principles and Practice of Geriatric Psychiatry, 3rd edn. Edited by Mohammed T. Abou-Saleh, Cornelius Katona and Anand Kumar 2011 John Wiley & Sons, Ltd
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use of percentile ranks serves a similar purpose, indicating whether a score is in the average range or is very infrequent and therefore unusual. Standard scores provide a consistent scale with a defined mean and standard deviation; for example, in the Wechsler Scale of Adult Intelligence (WAIS-III)3 , a scale with a mean of 100 and a standard deviation of 15 is used. Subtest scores are converted to this scale and overall scores are calculated on the same scale. Scores that are two standard deviations above or below the mean are generally considered exceptional, in that they arise very rarely. Scores of 70 (two standard deviations below the mean of 100) or below occur in approximately 5% or fewer of the population. Some tests use a mean of 10 and a standard deviation of 3; in this case, scores of 5 or below occur only in 5% or fewer of the population. With tests that use population-based norms, the fact that a score is unusual does not in itself indicate that there is an impairment. The observed score may simply reflect the individual’s long-standing ability level: the individual may be one of the 5% of the population who score very poorly on the task. Therefore, information about the expected level of performance is needed in order to interpret the results. If the individual’s performance is widely discrepant from what would be expected for that individual, this suggests there may be a difficulty or impairment resulting from illness or injury. In practice, expectations about likely performance are usually based on consideration of a number of factors such as the individual’s educational and occupational background and level of achievement. For a very high-achieving individual, a score that is in the low average range may reflect a significant decline from previous, superior performance levels. However, in some cases, tests are available that can provide an estimate of expected performance levels. For example, in the English language, the ability to read irregularly-spelled words can be tested with the Wechsler Test of Adult Reading (WTAR)4 or the National Adult Reading Test (NART)5 . Since this is considered a ‘crystallized’ ability, and fairly resistant to many forms of brain injury as well as the very early signs of dementia, scores on this task can be converted to obtain a predicted score on the WAIS-III3 . If comparing this predicted score with the observed score yields a significant discrepancy, with the observed score lower than the predicted score, this is suggestive of a decline in overall intellectual functioning. Similarly, a comparison might be made between the WAIS IQ score and the Wechsler Memory Scale (WMS-III)6 score; normative data are available to indicate whether or not a discrepancy in scores is large enough, and unusual enough, to be considered a significant indicator of an impairment in memory relative to what would be expected on the basis of the IQ score. With deficit-oriented tests, a score that would be unusual in the reference group is generally considered to provide an indication of impairment, given that the poor score cannot be explained by other, contextual factors. The 5th percentile often provides in effect a cutoff for identifying impairment. Scores at or below the 5th percentile in the normal population may be defined as falling into the impaired range. An example of a test using this approach is the Visual Object and Space Perception Battery7 . For tests using standard scores, as noted above, a score at or below the 5th percentile approximately translates into a score of 70 or below (on the scale with a mean of 100 and standard deviation of 15) or a score of 5 or below (on the scale with a mean of 10 and standard deviation of 3). Some tests use their own classifications, indicating whether a particular score is ‘impaired’, ‘poor’, or ‘normal’. An example of a test using this approach is the Rivermead Behavioural Memory Test8 . Some tests reflect tasks that should be achievable by anyone with normal functioning and thus the presence of errors in itself reflects likely
impairments; for example, the Behavioural Inattention Test9 identifies scores as impaired if they are below those of the lowest performing normal controls. Provision of appropriate test norms is not straightforward, and this is especially the case with older age-groups (for a fuller discussion of this issue, see Busch et al.2 ). Where tests were initially developed for younger adults, norms for older people may be unavailable, or may relate to a restricted age range. They may be based on more limited sample sizes than those for younger age groups, or may have drawn upon a non-representative sample containing only those highly motivated to assist with research. Some measures have only one set of norms available, while other frequently used measures offer numerous sets of norms among which the clinician can select those that are most appropriate for the patient and for the questions being addressed in the assessment. Details of many of these can be found in the compendium compiled by Strauss et al.10 . Cultural differences may mean that the available norms are not directly appropriate for the individual; for example, an individual who has grown up in a developing country and immigrated to the United Kingdom or United States as an adult will have had different formative and educational experiences from the indigenous population, and thus norms based on a United Kingdom or United States indigenous population may be inappropriate. This in itself does not necessarily preclude the use of the test, but the lack of appropriate norms will place constraints on the interpretation of results. Availability of neuropsychological tests in languages other than English is limited, and use of interpreters during testing is unsatisfactory, especially where these are family members. Translation of tests is a highly skilled and complex task and cultural, as well as linguistic, equivalence must be established. For a fuller discussion of cultural issues in assessment, see the review by Manly11 . Comparison with test norms provides an indication of the degree to which the observed score would be infrequent or unusual in a healthy population of the same age. In some cases, this is sufficient to clarify the presence of an impairment in a particular area. However, as noted above, the situation is not always clear-cut. Furthermore, individual test scores elicited on a given occasion may be affected by a range of factors. Some of these relate to the individual, for example low mood, anxiety about being tested, physical health problems, pain, drug effects or fatigue. Some relate to the testing environment, for example uncomfortable seating, inadequate lighting or high levels of noise. Other factors relate to the tests used, for example the extent to which they require dexterity or mobility, whether stimuli are in large enough print to be easily visible, and so forth. The extent to which the assessor is able to build rapport with the individual, and respond to any emotional reactions to the assessment, may influence motivation and willingness to engage. Therefore, individual scores must be interpreted in the context of the overall situation. The neuropsychologist’s observations of the individual during testing, and comments on the testing situation, will form an important part of the picture when drawing conclusions based on the test results. The neuropsychological assessment provides a profile of the individual’s strengths and difficulties. This profile may be used to contribute to problem identification or diagnosis, to inform decisions about treatment or management, or to monitor change over time. In so doing, information from the neuropsychological assessment must be considered alongside information obtained from other sources12 . The pattern of scores on neuropsychological tests is only one part of the picture, and needs to be considered alongside the medical history
DIAGNOSIS AND ASSESSMENT and the results of other tests, for example those that can detect possible physical causes of cognitive impairment, such as heart disease, vitamin deficiency or infection. It is also important to consider information about functional ability. Although cognitive status is related to functional ability13 , performance on cognitive tests does not fully predict functional ability. Therefore a direct assessment of activities of daily living may be advisable. See Little and Doherty14 and Chapter 34, for a discussion of assessment of functioning, behaviour and daily living skills. An informant perspective is extremely important and should be obtained wherever possible, with the informant interviewed separately in order to obtain a full account. A home visit can provide valuable insights into the person’s living situation and social networks. If results are unclear, they can be seen as providing a baseline, and testing can be repeated after a suitable interval (e.g. one year) to see if there has been any change. However, repeated testing may give rise to practice effects and therefore needs to be undertaken with a degree of caution, and only in those cases where it is really essential. Some tests provide parallel versions of equivalent difficulty which can be used for repeated testing, for example the Rivermead Behavioural Memory Test8 and the Test of Everyday Attention15 . The need for repeated assessment is particularly likely to arise in cases where the aim is to differentiate the very early stages of dementia from normal ageing, given the range of factors that can affect test performance on any given occasion. Sometimes the appropriate outcome of a neuropsychological assessment is a decision to re-evaluate after a period of time has elapsed. While there is sometimes pressure to assign a diagnostic category following initial assessment, it is very important for the sake of the individual and family to avoid the risk of a false-positive diagnosis, and in many cases the best approach is to reassess after a period of time has elapsed in order to monitor the presence or absence of change over time, which in itself may be the most significant diagnostic indicator1 .
AIMS AND SCOPE OF NEUROPSYCHOLOGICAL ASSESSMENT Usually a neuropsychological assessment will be indicated where information about the cognitive profile will assist in answering a specific question or set of questions. Perhaps the most common situation is the need to distinguish between normal ageing, mild cognitive impairment and the early stages of dementia, or to identify whether cognitive difficulties are the result of depression or mental health issues or an indication of early-stage dementia, or to distinguish between different subtypes of dementia or help identify the precise nature of the progressive neurological condition involved (see also Chapters 42 and 62). An assessment might be required in order to identify the presence and nature of cognitive difficulties following a stroke or in the context of other conditions such as Parkinson’s disease. In some cases, information from the neuropsychological assessment may be needed to contribute to decisions about ability to continue driving or about the extent to which the individual has capacity to make specific decisions and choices regarding, for example, medical treatment, financial affairs, or where to live. When conducting neuropsychological assessment with older people, it is important to have a sound knowledge of the profile of cognitive changes arising as a part of normal ageing, including the underlying neuroanatomy, as well as the diagnostic profiles of the range of relevant neurological and psychiatric disorders and their
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behavioural presentation in older people, and an understanding of the potential impact on cognition of neurological injury (for a fuller discussion of these issues, see by Potter and Attix16 ). Special considerations arise with regard to particular groups of older people, such as those with lifelong intellectual disability or those with long-term mental illness, where the availability of suitable tests may be limited and change may be especially difficult to detect (e.g.17 ). It is also necessary to be aware of the way in which neuropsychological factors relate to abilities such as driving or to definitions of capacity (for a fuller discussion, see pp. 175–87 in Zarit and Zarit1 ). While we typically think of cognitive functions as somewhat discrete entities, such as memory, attention or language, in practice these functions are closely interrelated. Changes in one may be mistaken for problems with another; for example an impairment in attention may mean that information is not encoded, giving the appearance of a problem with memory. Furthermore, if the assessment is contributing to a diagnostic process, sampling just one cognitive function will be inadequate; for example, a diagnosis of Alzheimer’s disease requires impairment in memory and at least one other cognitive domain. In most cases, it will be necessary to sample a broad range of cognitive functions. Generally it is the pattern of results across domains that is most informative. The questions that will be asked are first whether there is an overall decline in cognitive functioning; second whether there are impairments in specific domains and processes; and third, if the answer to either of these is affirmative, whether there are any factors other than neurological impairment that could account for the poor performance. Where neurological impairments are identified, this leads to the questions of what the pattern of impairments suggests, what are the implications for the individual’s daily life, and for the family where appropriate; and whether intervention is indicated. If there are factors other than neurological impairment that may be affecting performance, such as depression, then these may be treated prior to reassessment. It is also worth noting that some patients may not show any objective impairment, and in such cases it is necessary to consider the reasons for the expressed concern and how best to respond. In gathering the necessary information, various approaches can be taken. An extensive standard battery of tests can be applied to every individual, or tests can be selected on an individual basis for each new patient. Most commonly, clinicians use a combination of these two methods. A comprehensive selection of tests that covers the essential cognitive functions and is likely to help in answering the most important kinds of questions can be supplemented by the selection of particular tests that are appropriate for the particular questions raised by the individual patient’s profile and that make it possible to follow up on particular hypotheses that the clinician may have developed based on the initial test responses. For example, if initial testing suggests an impairment in language, attention or executive function, further tests can be selected to provide a more detailed profile. It is important to tailor the selection of tests to the level of functioning of the individual patient and the aims of the assessment. Thus, an assessment aimed at identifying very subtle difficulties that might constitute the earliest signs of dementia in a 65 year old would require a challenging and extensive set of tasks, while it would be more appropriate to test a patient who showed more obvious signs of impairment, or who was very frail, with a briefer neuropsychological screening battery, perhaps supplemented by one or two brief tasks. A comprehensive assessment will usually include an evaluation of general intellectual functioning (IQ). The most widely used test for
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this purpose is the WAIS-III3 . This includes seven tests of verbal ability (e.g. vocabulary, comprehension, digit span) and seven tests of performance ability (e.g. block design, picture arrangement, matrix reasoning). The full test is lengthy to administer but an overall score can be obtained by administering selected sub-tests or by using the Wechsler Abbreviated Scale of Adult Intelligence18 . Alongside this, a test that predicts lifelong optimal level of intellectual functioning, such as the WTAR4 , is usually administered. As discussed above, a significant discrepancy between predicted and current IQ would indicate a decline in current functioning. Several specific cognitive domains will also be assessed, typically visuo-spatial perception, language, attention, executive function (the capacity for abstract thinking, planning, problem-solving and inhibition), and memory. For a full discussion of these areas and of the tests that can be used to assess them, see books by Lezak et al.19 and Strauss et al.10 . Memory assessment will usually cover both long-term memory, comprising episodic memory (memory for personally experienced events) and semantic memory (memory for factual information) and working memory. It may also cover prospective memory (ability to remember future intentions) and autobiographical memory. As well as these types of memory, assessment should consider the processes that constitute memory and learning: registration and encoding of information, storage of information and recall of information. Memory should be tested in various ways including recognition, immediate recall and delayed recall, and in various modalities including visual and verbal. Where there has been a discrete injury or insult, such as a closed head injury or stroke, it is useful to consider whether memory difficulties relate to information acquired before the injury (retrograde) or since the injury (anterograde). One of the most widely used memory assessments is the WMS-III6 , which includes 11 subtests providing scores for general memory, working memory, immediate memory, auditory immediate memory, visual immediate memory, auditory delayed memory, auditory reception delayed and visual delayed memory. As with the WAIS-III3 , the WMS-III is a lengthy test and in some cases it may be appropriate to use only a selection of subtests. Many other tests are available to assess specific aspects of memory, for example the Rey-Osterrieth Auditory Verbal Learning Test (RAVLT)10 or California Verbal Learning Test (CVLTII)20 . The Rivermead Behavioural Memory Test8 focuses on everyday uses of memory, testing memory through the kinds of activities that require memory skills in daily life. Visual perception can be assessed with subtests from the Visual Object and Space Perception Battery7 , with figure drawing using the Rey-Osterrieth Complex Figure Test10 , or with the clock drawing test10 . Language is often assessed through tests of naming such as the Boston Naming Test21 or Graded Naming Test22 . Attention can be assessed with subtests from the Test of Everyday Attention, and executive function with subtests from the Delis-Kaplan Executive Function System (D-KEFS)23 , which include trail-making and verbal fluency. As noted above, neuropsychological screening batteries can be employed where patients have obvious impairments or are unable to complete a full assessment. An example of the latter is the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS)24 . This includes 12 subtests, providing scores in five categories: immediate memory, delayed memory, attention, language and visuo-spatial/constructional ability. The availability of parallel versions of equivalent difficulty is an advantage where repeated testing is indicated. For people with very marked impairments, the
Severe Impairment Battery25 assesses various aspects of cognition using a range of simple tasks.
THE PROCESS OF NEUROPSYCHOLOGICAL ASSESSMENT The process of conducting a neuropsychological assessment will be influenced by whether the neuropsychologist works as part of a multidisciplinary team or receives referrals as an individual professional. If working as part of a team, information about medical history and factors such as mental state and mood may be available from the psychiatric examination. These areas may therefore require less extensive evaluation as part of the neuropsychological assessment, although some investigation will still usually be made, and standard questionnaires such as the Hospital Anxiety and Depression Scale26 or Geriatric Depression Scale27 (see Chapter 29) may be used. The advantage of teamwork lies in drawing together the results of the neuropsychological assessment with the findings from other aspects of the assessment, including for example functional assessments conducted by an occupational therapist. In planning a neuropsychological assessment, the first consideration will be to ensure that sufficient time is available. A comprehensive assessment may require several hours’ contact with the patient and may need to be conducted over more than one visit. Even a brief assessment using a neuropsychological screening battery may take 1.5–2 hours. The neuropsychologist will require sufficient information to select an appropriate set of tests. It is particularly important for the neuropsychologist to be made aware of any factors that would influence the selection of tests, including illiteracy, sensory impairment, restricted mobility and likelihood of fatigue. It is essential that patients are asked to bring with them reading glasses and hearing aids if they use these. Cultural factors should also be considered. In particular, if English is not the patient’s first language, this will place constraints on the assessment. Even if the patient speaks very good English, comparison with norms derived from native speakers is unlikely to be appropriate. On meeting the patient, the neuropsychologist will be concerned to establish a good rapport and ensure that the patient fully understands the nature and aims of the assessment process. At this stage informal discussion can help to elicit the patient’s views about his or her difficulties, about the assessment and about the reasons for attending. If an informant is available, the neuropsychologist will want to talk with him or her individually as well as together with the patient. Patients are often anxious about being tested and worried about giving the wrong answers. It can be helpful to explain to them that the tests are designed to challenge everyone, so there is no expectation that anyone would get all the answers right, and the important thing is just to do the best they can. There is no doubt that patients, especially those in the older age groups, often find the neuropsychological assessment a strange process, but there is no need for it to be aversive if the neuropsychologist is able to develop a good rapport and show sufficient sensitivity. Throughout the assessment the neuropsychologist must be attentive to signs of fatigue and to expressions of frustration or distress. The former can be alleviated by suggesting a short break and offering refreshments, while the latter can be addressed by sequencing tasks so that tests which the patient finds difficult are followed by tasks that can be completed more easily. The neuropsychologist will also carefully observe the patient’s reactions and behaviour during the session in order to gain
DIAGNOSIS AND ASSESSMENT an impression of the patient’s level of motivation and awareness, and identify any factors that may have affected performance. Following the assessment, the neuropsychologist will calculate the patient’s scores on the various tests administered, a process which can be quite time-consuming, and will usually prepare a concise but comprehensive report detailing the results of the assessment28 . This will typically contain the following sections: background to the referral and any relevant history, and the reasons for the assessment; outline of the neuropsychologist’s observations of the patient’s behaviour and responses during testing; details of the tests administered; profile of results for each domain of cognitive functioning assessed; any additional data such as findings from questionnaires assessing mood; summary and recommendations. In the summary and recommendation section, the neuropsychologist will usually comment on the profile of results and what this implies; for example, he or she may comment that the profile is, or is not, consistent with a diagnosis of Alzheimer’s disease. This section will also contain any practical recommendations that the neuropsychologist is able to make regarding how to assist or support the patient and family, or improve management of the patient’s condition. The neuropsychologist will generally aim to meet with the patient, and if appropriate the family as well, to provide feedback on the results of the assessment. Feedback should be tailored to the needs and concerns of the patient and family. In the team context this meeting may be jointly arranged with another professional such as the psychiatrist. In some cases it may be necessary to convey unwelcome news such as the diagnosis of dementia. Diagnostic disclosure should be ‘patient led’ and based on the individual situation29 . The process should be conducted sensitively and sufficient time should be allowed to ensure that discussion is not rushed and that the patient and family are able to ask questions. A single meeting may not be adequate and it may be advisable to arrange a follow-up discussion. Emphasis should be placed on linking the patient and family with appropriate support networks and on identifying any possible treatment approaches. Finally, it is important to emphasize that the scope of the neuropsychological assessment is not restricted to assisting in reaching a diagnosis. Ideally, and perhaps particularly so in the case of older people, the knowledge gained about the patient’s strengths and difficulties in cognitive functioning as a result of the neuropsychological assessment will form a basis for offering information and advice about managing the patient’s condition or informing the development of a treatment plan30 based on principles of neuropsychological rehabilitation.
REFERENCES 1. Zarit SH, Zarit JM. Mental Disorders in Older Adults: Fundamentals of Assessment and Treatment, 2nd edn. New York: Guilford, 2007. 2. Busch RM, Chelune GJ, Suchy Y. Using norms in neuropsychological assessment of the elderly. In Attix DK, Welsh-Bohmer KM (eds), Geriatric Neuropsychology: Assessment and Intervention. New York: Guilford, 2006, 133–57. 3. Wechsler D. Wechsler Adult Intelligence Scale. Third UK edition (WAIS-III). London: Harcourt Assessment, 1999. 4. Wechsler D. Wechsler Test of Adult Reading (WTAR). San Antonio, TX: Harcourt Assessment, 2001. 5. Nelson HE, Willison JR. National Adult Reading Test , 2nd edn. Windsor: NFER-Nelson, 1991.
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6. Wechsler D. Wechsler Memory Scale. Third UK edition (WMSIII). London: Harcourt Assessment, 1999. 7. Warrington E, James M. Visual Object and Space Perception Battery. Bury St Edmunds: Thames Valley Test Company, 1991. 8. Wilson BA, Greenfield E, Clare L et al. Rivermead Behavioural Memory Test. Third Edition. (RBMT-3). London: Harcourt Assessment, 2007. 9. Wilson BA, Cockburn J, Halligan P. Behavioural Inattention Test (BIT). Bury St Edmunds: Thames Valley Test Company, 1987. 10. Strauss E, Sherman EMS, Spreen O. A Compendium of Neuropsychological Tests: Administration, Norms and Commentary, 3rd edn. New York: Oxford University Press, 2006. 11. Manly J. Cultural issues. In Attix DK, Welsh-Bohmer KM (eds), Geriatric Neuropsychology: Assessment and Intervention. New York: Guilford, 2006, 198–222. 12. Clare L. Neuropsychological assessment of the older person. In Woods WT, Clare L (eds), Handbook of the Clinical Psychology of Ageing, 2nd edn. Chichester: John Wiley & Sons Ltd, 2007, 363–83. 13. Marson D, Hebert KR. Functional assessment. In Attix DK, Welsh-Bohmer KM (eds), Geriatric Neuropsychology: Assessment and Intervention. New York: Guilford, 2006, 158–97. 14. Little A, Doherty B. Assessing functioning, behaviour and need. In Woods RT, Clare L (eds), Handbook of the Clinical Psychology of Ageing, 2nd edn. Chichester: John Wiley & Sons Ltd, 2007, 385–414. 15. Robertson IH, Ward T, Ridgeway V, Nimmo-Smith I. The Test of Everyday Attention. Bury St Edmunds: Thames Valley Test Company, 1994. 16. Potter G, Attix DK. An integrated model for geriatric neuropsychological assessment. In Attix DK, Welsh-Bohmer KM (eds), Geriatric Neuropsychology: Assessment and Intervention. New York: Guilford, 2006, 5–26. 17. Oliver C, Adams D, Kalsy S. Ageing, dementia and people with intellectual disability. In Woods RT, Clare L (eds), Handbook of the Clinical Psychology of Ageing, 2nd edn. Chichester: John Wiley & Sons Ltd, 2007, 341–59. 18. Wechsler D. Wechsler Abbreviated Scale of Adult Intelligence (WASI). London: Harcourt Assessment, 1999. 19. Lezak MD, Howieson DB, Loring DW. Neuropsychological Assessment , 4th edn. New York: Oxford University Press, 2004. 20. Delis DC, Kaplan E, Cramer JH, Ober BA. California Verbal Learning Test, second UK edition (CVLT-II). London: Harcourt Assessment, 2000. 21. Kaplan E, Goodglass H, Weintraub S. Boston Naming Test . Philadelphia: Lea and Febiger, 1983. 22. Warrington E. The Graded Naming Test: a restandardisation. Neuropsychol Rehabil 1997; 7: 143–46. 23. Delis DC, Kaplan E, Kramer JH. Delis-Kaplan Executive Function System (D-KEFS). London: Harcourt Assessment, 2001. 24. Randolph C. Repeatable Battery for the Assessment of Neuropsychological Status (RBANS-UK). London: Harcourt Assessment, 1998. 25. Saxton J, McGonigle KL, Swihart AA, Boller F. The Severe Impairment Battery. Bury St Edmunds: Thames Valley Test Company, 1993. 26. Snaith RP, Zigmond AS. The Hospital Anxiety and Depression Scale. Windsor: NFER-Nelson, 1994.
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27. Yesavage JA, Brink TL, Rose TL et al. Development and validation of a geriatric depression screening scale: a preliminary report. J Psychiatr Res 1983; 17: 37–49. 28. Green J. Feedback. In Attix DK, Welsh-Bohmer KM (eds), Geriatric Neuropsychology: Assessment and Intervention. New York: Guilford, 2006, 223–36.
29. Bamford C, Lamont S, Eccles M, Robinson L, May C, Bond J. Disclosing a diagnosis of dementia: a systematic review. Int J Geriatr Psychiatry 2004; 19: 151–69. 30. Clare L. Neuropsychological Rehabilitation and People with Dementia. Hove: Psychology Press, 2008.
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Overview of Rating Scales in Old Age Psychiatry Kenneth C. M. Wilson, Ben Green and Pat Mottram Department of Psychiatry, University of Liverpool, UK
SOME OF THE ISSUES
THE DEVELOPMENT OF A RATING SCALE
The needs which rating scales are expected to fulfil in the psychiatry of old age differ little from those in other age groups. However there are a few issues, which are worth considering. The rating of behaviour concerned with the ageing process remains a contentious issue and does not play a significant role in driving the development of rating scales designed for this age group. The main influences have been the problems imposed by the measurement of psychiatric symptoms in the context of co-morbidity and the relatively high prevalence of organic cerebral disease experienced by older people. These two issues have informed the development of numerous rating scales for the assessment of cognition and have led to adaptation and subsequent development from many well-recognised rating scales used for the assessment of functional symptoms in younger people. Both significant physical morbidity and cognitive dysfunction will impact on the design as well as the content of the rating scale. Such rating scales need to be brief, allowing for problems in concentration and fatigue. Data may have to be recruited from sources other than the patient. In addition, it is important to emphasise the influence of age related cultural differences. It is usual for the interviewer to be as much as two generations younger than the interviewee. Such a generation gap will carry with it differing expectations, understandings and experiences. An interesting example of this is that up to one third of older people say that they do not feel depressive mood when many other symptoms point inevitably to the presence of a depressive syndrome. This is unlike the experience of other age groups. It is tempting to introduce the concept of denial when trying to explain this. However, it is just possible that older people understand the term differently or have, throughout their life described the feeling of depression differently; such as feeling ‘empty inside’. If a particular rating scale is weighted so as to emphasise the importance of experiencing depressed mood then it may well not address the experiences of a significant proportion of older people with depressive syndrome. A well-recognised book, devoted to the compilation of rating scales in old age psychiatry lists well over 200 different rating scales1 . It is well beyond the scope of this brief overview to provide a comprehensive review of each of these instruments. However, as the field of instrumentation expands it is equally important to draw attention to issues relating to the development and selection of these rating scales.
A number of approaches have been taken in developing rating scales. Good examples are found in scales designed to rate depression; some are developed from ‘gold standard’ diagnostic criteria. For example, the OARS Depressive scale2 is derived from depressive symptoms listed by DSM III diagnosis. Other scales have been developed from already existing rating scales. A good example of this is the Carroll Rating Scale (CRS)3 which was developed from the Hamilton Depression Rating Scale and the Beck Depression Inventory. Being aware of the developmental source of an individual instrument will inform choice in the context of the purpose and population in which the instrument is to be applied. For example, there are significant and important questions relating to the validity of DSM criteria in the diagnosis of depression in people with other disorders such as Parkinson’s disease11 . This generates the obvious question as to whether rating scales derived from these criteria are suitable for, or have been validated in these specific populations. Likewise, those rating scales that have been developed from other rating scales pose the same questions; have the source rating scales been validated in the target populations? Has there been subsequent validation of the specific rating scale in the relevant population? An obvious example is the use of rating scales for rating depression in patients with dementia. Another lies in the problem of rating depression in people with significant physical illness, where some of the physical illness symptoms, such as appetite loss; may be the same as some of those that are rated as depressive symptoms by the scale. The same issue relates to rating scales designed to rate cognitive symptoms. The Mini Mental State Examination4 is probably one of the most commonly used cognitive assessment instruments. Its original purpose was to differentiate organic from functional disorders and was designed to quantify change in cognitive state. Despite its popularity, the instrument does have its critics as a screening instrument5 . There are two important issues worth highlighting in relation to its use. Firstly, the instrument does not and should not be used to allocate a diagnosis. When used in the context of an acute medical ward, it is as likely to pick up cognitive deficit in people with acute confusional states as a consequence of physical illness as it is to identify cognitive problems associated with dementias. Secondly, the instrument fails to assess all cognitive domains, in particular, failing to address specific deficits relating to frontal cortex. This problem is reflected in the adaptation of the instrument over many years of use.
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A good example of this is the development of the ACE-R12 , which was derived from the Mini Mental State Examination but includes a section addressing frontal lobe assessment.
VALIDITY OF AN INSTRUMENT Many of the above issues fall within the over-all heading of ‘validity’. Proving the validity of an instrument is seminal to its development. The concept addresses a number of issues in which the characteristics of the instrument in terms of its performance are addressed within defined populations. Hence, an instrument may be valid in one setting (or in rating symptoms in one type of population) but may not be valid in another. In testing the validity of an instrument; the degree to which it adequately probes the specific issues that are being rated is tested. Its ability to differentiate between people that are known to be dissimilar is tested, and finally, the instrument is examined in terms of the demonstrating that certain explanatory constructs account to some degree for the performance of the test. From a practical point of view it is critical that the choice of an instrument is informed by evidence of validation in populations similar to those that are intended to be interviewed. Many rating scales have been developed as potential ‘case’ finding instruments. Usually a rating scale will generate a numerical ‘score’, often purported to represent severity of a particular set of signs or symptoms. Common examples include the Geriatric Depression Scale. The scale is not a diagnostic instrument in that it does not exclude conditions, other than depression, which might affect its performance. However it can be used as a screening instrument in that, using a ‘cut-off’ score it will identify individuals with a degree of symptom severity that correlates with a depression diagnosis. This is done by examining the sensitivity and specificity of the instrument in relationship to an already established instrument or other clinical criteria. In the case of the full, 30-item Geriatric depression Scale; a cut-off score of 11 has been established6 . However this is further complicated by subsequent developments of the instrument. There now exist shortened versions of 15, 10 and four items, all of which have different ‘cut-offs’. It is self-evident that when choosing an instrument the right ‘cut-off’ score should be used. Many studies fail to report which version of the instrument is used, making comparisons between studies and study replication very difficult.
RELIABILITY OF THE SCALE Understanding why the instrument was developed in the first place, the subsequent evolution of the instrument and being aware of the populations in which the instrument has proven validity are critical in informing choice of instrument. The ‘Relaibility’ of the instrument must also be considered. This is a technical term referring to a number of concepts. Firstly; the internal consistency of an instrument refers to the reproducibility of measurement across different items within the rating scale. The ‘test-retest reliability’ refers to the likelihood of the instrument producing similar ratings when consecutively conducted on the same patient (assuming the condition being measured has not changed in the intervening period).
Secondly; the inter-rater reliability refers to the likelihood of the instrument producing similar results when delivered by two different interviewers simultaneously. Obviously, the interviewer plays an important role in terms of reliability performance. This issue is generally addressed (particularly in the context of research) through training and standardisation. Unfortunately, this is not common practice in clinical settings. The implications of this can be fairly profound in terms of patient care. Again, taking the example of the Mini Mental State Examination; which is recommended in the rating of change in cognition in the context of prescribing anticholinesterase inhibitors in England and Wales. If the instrument is not used in a standardised way then the generated scores will vary; affecting patient care. However, when used appropriately the reliability is fairly good7 . Another area of potential concern lies in applying those rating scales employing graded or continuous variables in rating individual items. An example of this is the Nursing Home Behaviour problem Scale10 . This instrument requires a rating of ‘never’, ‘sometimes’, ‘often’, ‘usually’ and ‘always’. Each of these options is associated with a different score. One of the problems facing the rater will lie in the differentiation between these grades. For example, how does one consistently differentiate between’ often’ and ‘usually’? The answer lies in clear instructions/descriptions and standardisation through training of the raters. A good example of a well-established and reliable instrument of this nature is the BECK Depression Inventory13 (not specifically designed for older people), which rates each item 0–3. Each score has a brief but clear description associated with it, facilitating high levels of reliability. This is one of many selfrating scales.
DIFFERENT METHODS OF DELIVERY Another typical example of a self-rating scale, specifically designed for older people is the SELF-CARE D rating scale9 . It is derived from the Comprehensive Assessment and Referral Evaluation Schedule (CARE)8 and is used to differentiate between people with and without depression in primary care settings. It takes about 15 minutes to complete. The advantages of using self-rating scales have to be balanced by the disadvantages. Experience suggests that the apparent time and resource savings may be offset by the frequent need to help people complete them. Obviously, the patient population must be able to read the questions (if required) and understand the instructions. The BASDEC is a hybrid rating scale, designed to measure depression in institutionalised settings in which patients may be over-heard or embarrassed by answering sensitive questions out loud. Nineteen cards with statements on are presented to the patient and the patient indicates whether each statement is true or false. Each ‘True’ answer generates a score of ‘1’, ‘don’t know’ generates a score of half a point and ‘false’ generates a ‘0’ score. Some scales are specifically designed to capture information about the patient from other sources. The Cornell Scale for Depression in Dementia has been designed to capture information from informants and through observation14 . The Dysfunctional Behaviour ∼Rating Scale15 was designed for carers to make observations relating to older people with cognitive impairment. In particular cases, data may be gleaned from either the patient or the rater; as is the case in the ‘Quantification of physical illness in psychiatric research in the elderly’16 .
DIAGNOSIS AND ASSESSMENT
TYPES OF INSTRUMENTS Even though some rating scales have been developed as screening or ‘case finding’ instruments; these should not be confused with diagnostic instruments that have been specifically designed to enable an allocation of a standardised diagnosis. Such instruments are usually derived from diagnostic systems such as the International Classification of Diseases (ICD) or the Diagnostic and Statistical Manual (DSM criteria). These are usually semi-structured interviews in which a psychiatric syndrome is established. Importantly, they will often include’ exclusion criteria’ in which specific psycho-syndromes are excluded as part of the process in establishing a diagnosis. For example, the exclusion of cerebro-vascular disease will influence the certainty by which Alzheimer’s Disease may be diagnosed. Rating scales are specifically designed to rate specific variables and can usually be classified by the nature of the variables that they are designed to rate. This overview has already drawn on rating scales designed to measure depression severity, physical illness severity and behavioural problems in people with cognitive disturbance. There are of course, a wide variety of instruments including those designed more specifically for rating aspects of the dementias, quality of life, morale, issues relating to carers and activities of daily living performance. In addition to the Mini Mental State Examination, there are a number of rating scales designed to rate memory and other aspects of cognition. A good example of a practical and innovative instrument is the IQCODE17 , which is used with an informant to quantify cognitive decline over time. These rating scales should not be confused with formal psychometric assessments usually carried out by experienced and trained psychologists.
RATING SCALE SELECTION In the first instance it is important to establish why and when a rating scale should be used. Staff on acute medical wards often use rating scales for the identification of patients with dementia and may use these to trigger referral for psychiatric assessment. Often enough, the psychiatrist will be referred a patient in an acute or sub-acute confusional state as a consequence of unstable physical illness. This is a classical mistake in that the rating scale is being used as a surrogate diagnostic instrument for dementia as opposed to a screening instrument for cognitive impairment. Inherent to this, is the question ‘what is intended to be measured?’. Once the answer to this question has been established then a rating scale developed and designed to measure particular criteria can be selected. The next issue to determine is whether the rating scale is designed to measure the symptoms in populations similar to that in which it the ratings are intended. Determination of this will go some way in establishing the valid use of the rating scale in any particular setting. The next question worth considering is whether the rating scale is to be used as a screening instrument or to measure change over time. If used as a screening instrument then it is important to determine the appropriate ‘cut-off score’. Again this might be specific to a particular population and may need some background literature research. As already mentioned, rating scales can be completed by the individual target patient or carer, by the interviewer or by a third party and by a mixture of agents. The choice will depend on the reasons why a
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scale is being used and whether or not the person who is subjected to the interview is able to actively contribute towards the rating. Other considerations relating to choice include; the length of the procedure. In patients with severe illness or short attention span, long interviews may prove problematic. As already indicated, training is required for some rating scales. This is important in terms of validity, reliability and generalisability of the findings. Research protocols in which rating scales are utilised will often include training and subsequent standardisation and inter-rater reliability sessions over the period of data collection. Lastly, the use of many commonly used rating scales are restricted by copyright.
SUMMARY This brief overview of the use of rating scales in old age psychiatry has attempted to provide a general background to the development of rating scales, drawing on examples of commonly used rating scales in Old Age Psychiatry. The practical implications of validity and reliability of rating scales have been exemplified in the context of selection of rating scales within this age group. As rating scales develop, health expectations increase and resources become more limited, rating scales may offer an apparent, easy alternative to comprehensive psychiatric assessment. It is important to remember; rating scales are refined and specific and if used inappropriately are likely to cause as much harm as they can good.
REFERENCES 1. Burns A, Lawlor B, Craig S 2004, Assessment scales in Old Age Psychiatry. 2nd Ed. Pubs; Martin Dinitz, London. 2. Blazer D. Thediagnosis of depression in the elderly. Journal of the American Geriatrics Society 1980; 28: 52–58. 3. Carroll BJ, Feinberg M, Smouse PE, Rawson SG, Greden JF. The Carroll rating scale for depression1. Development, reliability and valiodation. British Journal of Psychiatry 1981; 1238: 194–200. 4. Folstein MF, Folstein SE, McHugh PR. Mini MnetalStae; a practyical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research 1975; 12: 189–198. 5. Anthony J, LeResche L, Niaz U et al. Limits of the Mini mental State as a screening test for dementias and delirium among hospital patients. Psychological Medicine 1982; 12: 397–408. 6. Brink T, Yesavage J, Lum O et al. Screening tests for Geriatric depression. Clinical gerontologist 1982; 1: 37–43. 7. Tombaugh TN, McIntyre NJ. The Mini Mental State Examination: a comprehensive review. Journal of the American geriatrics society 1992; 40: 922–35. 8. Guralnd B, Kuriansky J, Sharpe L et al. The Comprehensive Assessment and Referral Evaluation (CARE) – rationale, development and relaibilty. International Journal of Ageing in Human development 1997; 8: 9–24. 9. Bird AS, macDonald AJD, Mann AH, Philpot MP. Preliminary experience with the SELFCARE-D: a self rating depression qusestionnaire for the use in elderly, non-institutionalised subjects. International Journal of geriatric psychiatry 2: 31–8. 10. Taylor R, Lichtenstein MJ, Meador KG. The Nursing Home behaviour Problem Scale. Journal of gerontology 1992; 47: M9–16.
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11. Weintraub D, Morales KH, Morberg PJ et al. Antidepressant studies in Parkinson’s Disease: a review and meta-analysis. Movement Disorders 2005; 20: 1161–1169. 12. Mioshi E, Dawson K, Mitchell J et al. The Addenbrooke’s Cognitive Examination Revised (ACE-R): a brief cognitive test battery for dementia screening. Int J Geriatr Psychiatry 2006; 21: 1078–1085. 13. Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J. An inventory for measuring depression. Archives of General Psychiatry 1961; 4: 53–63. 14. Alexopoulos GS, Abrams RC, Young RC, Shamoian CA. Cornell Scale for Depression in Dementia. Biological Psychiatry 1988; 23: 271–84.
15. Molloy DW, McILroy WE, Guyatt GH, Lever JA. Validity and reliability of the Dysfunctional Rating Instrument. ActaPsychiatricaScandinavica 1991; 84: 103–6. 16. Burvill PW, Mowry B, Hall WD. Quantification of physical illness in psychiatric research in the elderly. International Journal of Geriatric Psychiatry 1990; 5: 161–170. 17. Jorm A. The informant questionnaire on cognitive decline in the elderly (IQCODE): A review. International Psychogeriatrics 2004; 16.3: 1–19c.
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The Mini-Mental State Examination∗: A Brief Cognitive Assessment Marshal Folstein1 , Susan Folstein1 and Jonathan Folstein2 1 University
of Miami Miller School of Medicine, Nashville, USA 2 Vanderbilt University, USA
The Mini-Mental Status Examination (MMSE) is a scored, 10-minute form of the traditional cognitive mental status examination. The items include orientation to place and time; registration and recall; attention and calculation; language function; and praxis. It is ‘mini’ because it tests cognitive aspects of mental functions, but excludes mood, abnormal mental experiences, and the form of thinking1 . It has been standardized with normative values for age and education and is used by physicians and other clinical professionals worldwide to estimate and communicate the presence and severity of cognitive impairment2,3 . The easily understandable items are useful for helping subjects and caregivers to understand the overall severity of cognitive impairment, as well as particular areas of deficits. For example, caregivers benefit from knowing that the patient can understand a one-stage command: ‘put on your socks’, but not a three-stage command: ‘put on your socks, your shoes, and your pants’. We highlight several instructions from the manual. First, a single administration given under supervision is adequate for training. Second, subjects should receive an explanation of why they are being tested and how the answers might help in their care or, in the case of research, accomplish the aim of the study. Third, successes should be praised, but errors ignored to avoid inducing emotions that might lower the subject’s cognitive capacity. Fourth, fearful subjects can be reassured by early success by beginning with easier items such as naming a pencil and watch. Finally, we recommend that the serial sevens test be given, followed by world-backwards only if the subject refuses to do serial sevens, or refuses to complete one subtraction. The world task is easier than serial sevens and decreases the sensitivity of the test. A score below 24 detects cognitive impairment in most populations4 while a score below 27 suggests the need for an evaluation of individuals with greater than a 10th grade education. The MMSE has significant floor and ceiling effects. Many severely impaired patients score zero and the MMSE does not assess superior cognitive capacity. The MMSE can be used in any population or cultural group; authorized translations are available from the publisher. The distribution ∗ Disclosure: The Mini-Mental State Examination (MMSE) and all its authorized translations are published by PAR, from which the authors receive royalties. Manuals and forms are available at Mini-Mental.com.
of scores in some populations is lower than those established in the United States. This mainly is due to lower education. In the cultures studied to date, the scores are comparable when education is taken into account. The relationship between education and MMSE reflects social class, nutrition, intelligence and other exposures that affect cognition. Low education is also a risk for some diseases that affect cognition. The MMSE score is thus a snapshot of the end result or composite of the many factors that have influenced cognition over the life span: social class, nutrition, intelligence, disease, and other exposures that have occurred throughout life. If the effects of disease and education are controlled, the effect of age on the MMSE is small.
RELIABILITY AND VALIDITY The MMSE has excellent test–retest and inter-rater reliability. The MMSE accurately reflects the results of psychological tests and structural and functional measures of brain pathology. For example, the MMSE correlates significantly with the Wechsler Adult Intelligence Scale and many other neuropsychological measures of memory, attention, executive function and language. MMSE has been shown to decline on average 3.3 points per year in Alzheimer’s disease and correlates with the severity of pathology found at autopsy or by structural and functional imaging5 . The MMSE score improves in response to treatments such as donepezil for Alzheimer’s disease6 . The score of MMSE is more similar in elderly identical twins than fraternal twins, suggesting a strong genetic component to the score. By these methods, the MMSE is 50% heritable in older adults from several countries, i.e. genetic factors account for about half the variance in scores. Low MMSE scores occur with dementia, delirium, mental retardation, cortical and subcortical dementia and discrete cognitive disorders such as amnesia, aphasia and executive dysfunction. Hearing-impaired and vision-impaired subjects obtain lower MMSE scores. However, if instructions are written, MMSE can be used with hearing-impaired persons. Vision is required for only two points on MMSE. Although the MMSE is often low in frontal/subcortical dementia as occurs in Huntington’s disease, Parkinson’s disease, AIDS
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dementia and frontal dementia, MMSE is less sensitive to early frontal/subcortical than to cortical dementia. Because of these limitations, we have recently published a revision of the MMSE (MMSE∼2), which includes tests that are more sensitive to subcortical cognitive impairment. Low MMSE scores occur in elderly depressed patients; many depressed patients with cognitive impairment later show cognitive deterioration. The MMSE can be used to track delirium but because the cognitive state in delirium fluctuates, MMSE reliability and sensitivity are difficult to determine. The reliability and validity of the MMSE has not been established for children or for developmental disorders of cognition. The MMSE score does not provide a diagnosis, pathology or aetiology, which must instead be established from the patient’s history, physical examination and laboratory findings. Nor does the MMSE define competency to perform complex social functions, such as giving informed consent or driving an automobile; these functions must be tested directly.
REFERENCES 1. Folstein MF, Folstein SE, McHugh PR. ‘Mini-mental state’. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975; 12(3): 189–98.
2. Anthony JC, LeResche L, Niaz U, von Korff MR, Folstein MF. Limits of the ‘Mini-Mental State’ as a screening test for dementia and delirium among hospital patients. Psychol Med 1982; 12(2): 397–408. 3. Crum RM, Anthony JC, Bassett SS, Folstein MF. Populationbased norms for the Mini-Mental State Examination by age and educational level. JAMA 1993; 269(18): 2386–91. 4. Tombaugh TN, McIntyre NJ. The Mini-Mental State Examination: a comprehensive review. J Am Geriatr Soc 1992; 40(9): 922–35. 5. Bancher C, Jellinger K, Lassmann H, Fischer P, Leblhuber F. Correlations between mental state and quantitative neuropathology in the Vienna Longitudinal Study on Dementia. Eur Arch Psychiatry Clin Neurosci 1996; 246(3): 137–46. 6. Wallin AK, Andreasen N, Eriksson S. Donepezil in Alzheimer’s disease: what to expect after 3 years of treatment in a routine clinical setting. Dement Geriatr Cogn Disord 2007; 23(3): 150–60.
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The Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) Nicolas Cherbuin1 and Anthony Francis Jorm2 1 Centre
2
for Mental Health Research, Australian National University, Canberra, ACT, Australia ORYGEN Research Centre, University of Melbourne, Department of Psychiatry, Parkville, Victoria, Australia
INTRODUCTION Efficient early detection of cognitive decline and dementia is becoming increasingly important. A large number of screening instruments are available, but they vary greatly in their ease of use, psychometric properties and validity in differing cultural contexts, as well as in the presence of co-morbid conditions. In addition, there is a need for cost-effective screening tests which can be administered to large populations across a variety of mediums (orally, paper and pencil, by mail, by telephone, or by computer). The Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) is a brief questionnaire for the assessment of change in cognition which shows very good psychometric properties, has been validated across multiple cultural contexts, and which can be used in clinical practice as well as in large-scale epidemiological studies. The IQODE was developed to assess cognitive decline from a pre-morbid level based on informant reports1 . The parent instrument was composed of 39 interview questions assessing memory function (acquisition and retrieval) and intelligence (verbal and performance). Informants were asked to rate the magnitude of change over the previous 10 years in these domains. After initial evaluation, the number of items was reduced to 26 which correlated well together and were relatively easy to rate. The questionnaire was formatted for selfcompletion and named IQCODE. In its present form the IQCODE requires each item to be rated on a 5-point scale from 1, ‘much improved’ to 5, ‘much worse’2 . The questions are framed in the form: ‘Compared to 10 years ago, how is this person at . . . ’ (e.g. remembering things about family and friends such as occupations, birthdays, addresses, etc.). A short version of the IQCODE consisting of 16 items has been developed2 . It was found to correlate highly (0.98) with the full version and to have equivalent validity against clinical diagnosis. Consequently there is little advantage in using the longer version. Versions of the IQCODE have been developed and validated in other languages (Chinese, Dutch, Finnish, French, Canadian French, German, Italian, Japanese, Korean, Norwegian, Persian, Polish, Portuguese, Spanish, and Thai) and copies are available for download at cmhr.anu.edu.au/ageing/iqcode.
Other variations on the IQCODE have also been produced, including questionnaires based on shorter3,4 or more flexible5 retrospective time frames, as well as short forms in Spanish6 , Chinese7 , Portuguese8 and in other languages (which to our knowledge have not been validated).
SCORING Scoring the IQCODE involves summing the items and dividing by the number of items, thus producing a measure ranging from 1 to 5, however, some investigators have preferred adding up all items. Norms have been developed by Jorm and Jacomb9 for five-year age groups from 70 to 85+ years, but in practice individual researchers have generally chosen to use an absolute cut-off ranging from 3.3–3.6 in community samples to 3.4–4.0 in patient samples. A practical strategy to choose a cut-off is to identify studies (e.g. in Table 28.1) with characteristics most similar to the target population and select their cut-offs.
ADMINISTRATION The IQCODE is a pen and paper test which takes between 10 and 25 minutes to complete, depending on the form chosen (long/short) and is generally perceived as relatively easy to answer. It can be mailed to informants and could potentially be administered by telephone or by computer (although we are not aware of any validation data with these administration media). The IQCODE can also be used as an alternative screening test when individuals are not able to complete another test such as the Mini-Mental State Examination (MMSE). In a survey of 839 community-based older individuals, Khachaturian et al.10 found 74 subjects who were unable to complete the 3 MS but the IQCODE could be completed by an informant. Seventy-one of these were subsequently diagnosed with dementia. In addition, Cherbuin et al.11 reviewed the literature to assess the suitability of dementia screening instruments for self- or informantassessment, particularly in an electronic format (local computer or web-based). They concluded that the IQCODE was one of three most
Principles and Practice of Geriatric Psychiatry, 3rd edn. Edited by Mohammed T. Abou-Saleh, Cornelius Katona and Anand Kumar 2011 John Wiley & Sons, Ltd
Epidemiological study (Australia) Ex-servicemen (half former prisoners of war) (Australia) Neurology clinic outpatients (Spain) Medical inpatients (England) Memory clinic patients (Australia) Dementia clinic patients and stroke patients (Singapore)
IQCODE (long version) Jorm et al. (1991)18 Jorm et al. (1994)40 Law and Wolfson (1995)36 Fuh et al. (1995)7 Morales et al. (1997)14 Morales et al. (1997)14 Jorm et al. (1996)27 Mulligan et al. (1996)37 Del-Ser et al. (1997)38 Flicker et al. (1997)53 Flicker et al. (1997)53 De Jonghe (1997)12 Senanarong et al. (2001)54 Lim et al. (2003)55 Stratford et al. (2003)56 Tang et al. (2003)15 Isella et al. (2006)21
IQCODE (short version) Jorm (1994)2 Jorm et al. (1996)27 Del-Ser et al. (1997)38 Harwood et al. (1997)57 Knafelc et al. (2003) Narasimhalu et al. (2007)58
1 3 1 1 1 2
3, 4 1 1 1 1 1 3 1 1 1, 5 1, 5 1 2 2 4 2 6
1 2 6
2 1, 4
1 1 1 2
Diagnostic criteriaa
3.38 3.38+ 3.88 3.44 3.60+ 3.38+
3.60+ 3.60+ 3.30+ 3.40+ 3.27+ 3.31+ 3.30+ 3.60+ 3.62+ 3.9 3.9 3.90+ All 3.40+ 4.00+ 3.40+ 3.45
23/24 23/24 23/24 23/24 25/26 28
21/22 21/22 23/24 23/24
Cutoff
684 144 53 177 323 576
69 684 237 399 97 160 144 76 53 299 78 82 87 153 577 189 100
104 287 144 323 183 100
97 160 344 46
N
a 1 = DSM-IIIR dementia; 2 = DSM-IV dementia; 3 = ICD-9; 4 = ICD-10 dementia; 5 = Clinical diagnosis; 6 = Mild cognitive impairment (Petersen 1996 criteria).
Patients seen by a geriatrician (Australia) Epidemiological study (Australia) Epidemiological study (Canada) Non-demented community resident and dementia patients (Taiwan) Urban epidemiological study (Spain) Rural epidemiological study (Spain) Ex-servicemen (half former prisoners of war) (Australia) Geriatric patients (Switzerland) Neurology clinic outpatients (Spain) Memory clinic patients (young, Australia) Memory clinic patients (old, Australia) Psychiatric patients (49 with dementia) (Netherlands) Community elderly (Thailand) Cognitively normal volunteers and 53 dementia patients (Singapore) Memory clinic patients (Australia) Stroke patients (China) Cognitively normal volunteers and 45 MCI patients (Spain)
Ferrucci et al. (1998)48 Heun et al. (1998)49 Jorm et al. (1996)27 Knafelc et al. (2003)52 Nasreddine et al. (2005)50 Isella et al. (2006)21
Sample
Urban epidemiological study (Spain) Rural epidemiological study (Spain) Epidemiological study (USA) Primary care clinic outpatients and independent retirement community residents (USA) Geriatric clinic patients (Italy) Epidemiological study (Germany) Ex-servicemen (half former prisoners of war) (Australia) Memory clinic patients (Australia) Memory clinic patients (Canada) Cognitively normal volunteers and 45 MCI patients (Spain)
MMSE Morales et al. (1997)14 Morales et al. (1997)14 Callahan et al. (2002)47 Swearer et al. (2002)51
Study
70+ 73 69 65+ 44–93 66
80 70 81 69 75 74 73 82 69 73 80 78 52–85 – 73 68 71
75 77 73 75 75 71
75 74 74 80
Age/Age range
0.79 0.75 0.79 1.00 0.94 0.78
0.80 0.69 0.76 0.89 0.82 0.83 0.79 0.76 0.84 0.74 0.79 0.88 – 0.94 – 0.88 0.84
0.97 0.84 0.45 0.84 0.78 0.82
0.73 0.83 0.95 0.13
Sensitivy
0.82 0.68 0.73 0.86 0.47 0.86
0.82 0.80 0.96 0.88 0.90 0.83 0.65 0.70 0.73 0.71 0.78 0.79 – 0.94 – 0.75 0.75
0.55 0.99 0.99 0.73 1.00 0.73
0.78 0.74 0.87 1.00
Specificity
Table 28.1 Performance of the Mini-Mental State Examination (MMSE), and the long and short versions of the IQCODE as a screening test for dementia47 – 51
0.85 0.77 0.77 – 0.82 0.89
0.87 0.77 – 0.91 0.89 0.83 0.77 0.86 0.81 – – – 0.93 – 0.82 0.88 –
– – 0.81 0.86 – –
– – 0.96 –
ROC curve
148 PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRY
DIAGNOSIS AND ASSESSMENT promising tools and they recommended further validation studies for these delivery platforms.
PSYCHOMETRIC CHARACTERISTICS The IQCODE’s reliability and validity have been extensively researched. A number of studies have assessed the internal consistency of the scale using Cronbach’s alpha. Alpha was found to range between 0.93 and 0.97 across nine studies1,7,9,12 – 17 which can be regarded as excellent. The stability of scores over short periods was found to be high, with test–retest reliability showing correlations of 0.96 over three days and 0.75 over one year9,18 . Other studies have conducted factor analyses to investigate the factor structure of the IQCODE. They all found a large main factor accounting for 42–73% of the variance which is thought to represent ‘cognitive decline’, while other factors were generally small with the second factor explaining less than 10% of the variance7,9,13,14,17,19 .
VALIDATION AGAINST CLINICAL DIAGNOSIS Many studies have assessed the validity of the IQCODE against clinical diagnosis. Table 28.1 contrasts measures of sensitivity and specificity of the long and short forms of the IQCODE and the MMSE11,20 and shows comparable findings for the two tests, confirming that the IQCODE is a valid screen for dementia. However, moderate correlations between the IQCODE and the MMSE in 15 studies ranging from −0.37 to −0.7820 with a sample size weighted average of −0.58 suggest that these two tests, although largely overlapping, each have some unique variance. As a consequence, a number of studies have investigated whether the concurrent administration and scoring of the IQCODE and the MMSE improves dementia detection. They generally reported somewhat increased sensitivity and/or specificity of the combined tests, but cost-benefits of this combination varied depending on the methodology or the type of sample used20 . The IQCODE has also been investigated as a predictor of conversion to mild cognitive impairment over three years and was found to be as sensitive as the MMSE for this population (sensitivity 0.82, specificity 0.71 for a cut-off of 3.19)21 . In addition, the IQCODE has been shown to be a predictor of incident dementia in stroke patients22 and in non-demented hospital inpatients23 over 2–3 years follow-up. However, application of the IQCODE to complex clinical populations should be considered carefully, as one study found that the IQCODE and the MMSE were poor at detecting dementia in a sample of first-ever stroke patients24 .
VALIDATION AGAINST NEUROPATHOLOGY AND NEUROIMAGING Diagnoses of dementia based on post-mortem histological examinations have been compared to pre-mortem IQCODE scores in two studies. Using a cut-off of 3.7 and a neuropathological diagnosis of Alzheimer’s disease, Thomas et al.25 found the IQCODE to have a sensitivity of 73% and a specificity of 75%. While Rockwood et al.26 , with a cut-off of 3.42 and a diagnosis of Alzheimer’s disease, vascular or mixed dementia, reported a sensitivity of 97% and a specificity of 33%. Another six studies found associations between neuroimaging measures and the IQCODE. Jorm et al.27 found significant associations between the IQCODE and the width of the third ventricle (r = 0.29), and infarcts in the left (r = 0.35)
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and right (r = 0.26) hemispheres in a community sample of older ex-servicemen. Cordoliani-Mackowiak et al.28 reported significant correlations between leukoaraiosis (r = 0.38) and IQCODE in elderly stroke patients. Henon et al.29 found significantly higher mean IQCODE measures in individuals with smaller medial temporal lobe measures. And in a diffusion tensor imaging study of stroke patients, Viswanathan et al.30 detected lower diffusion measures in the non-affected hemisphere, which were interpreted as showing decreased cerebral tissue integrity in those whose pre-morbid cognition was below a cut-off of 3.4 on the IQCODE. High scores on the IQCODE have also been associated with greater cerebral atrophy31,32 .
BIAS AND LIMITATIONS One complicating issue associated with many cognitive tests is that they can be open to bias when applied to specific sociodemographic, ethnic, language, gender, clinical or cultural groups. For example, scores on the most widely used dementia screening test, the MMSE, have been shown to be affected by gender, age, education, cultural background, language spoken at home, socioeconomic status, occupation and presence of a mood disorder33,34 . The IQCODE has been shown to be minimally influenced by education2,7,9,12,35 – 38 and by proficiency in the language of the country of residence39 . However, small associations between the IQCODE and anxiety and depression have been reported14,37,38,40 . They may be due to a direct link between mood disorders and cognitive function or to the fact that the informant may have difficulty differentiating between cognitive decline and depression and anxiety. In addition, the influence of informant characteristics has also been investigated as possible bias. Jorm et al.41 found that measures of informant anxiety, depression and their perception of how caring or controlling the subject was perceived to be were more strongly correlated with IQCODE scores than with the MMSE score. This suggests some contamination of the informant’s ratings by the respondent’s characteristics but these influences appear to be relatively weak and account for less than 6% of the variance in IQCODE scores. In contrast, the length and type of relationship and the age and education of the informant have not been found to be associated with the IQCODE7,42 .
OTHER APPLICATIONS Although the IQCODE was developed to assess cognitive decline from a premorbid state, it has also been used for other purposes. Priner and colleagues43 assessed the short form of the IQCODE as a screen for the prediction of postoperative delirium following hip or knee surgery and found that those with a score greater than 3.1 had a more than 12-fold increased risk of delirium. In another study, the premorbid cognitive status of stroke patients was assessed retrospectively with the IQCODE and those with a score greater than 4 were found to be at higher risk of developing epileptic seizures44 and of dying45 . Pasquini et al. also investigated the risk of institutionalization in stroke patients46 and found that those with an IQCODE score greater than 4 at admission had a higher risk of being institutionalized three years later. Finally, the feasibility of using the IQCODE as a self-report instrument has been investigated by Jensen et al.16 who administered the questionnaire by mail to 2841 individuals (58.9% of target population) initially recruited during general practice visits. They found
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that more than 60% reported completing the questionnaire without help and, although responses were not validated against full clinical diagnoses, mean IQCODE scores were higher (3.7 versus 3.3) in patients suspected of having dementia by their GP and the authors commented ‘the IQCODE-SR meets the basic requirements of a good measurement’.
CONCLUSION The IQCODE is a valid screening instrument for dementia and cognitive decline. It is particularly useful in assessing individuals with less proficient language skill, lower education levels or different cultural background or when direct cognitive testing is not possible. Its administration in conjunction with other tests (e.g. MMSE) can improve overall detection rates. Its ease of use and format make it suitable for use in clinical settings as well as in large epidemiological studies.
Acknowledgements Cherbuin is funded by the National Health and Medical Research Council (NHMRC) Fellowship No. 418020. Jorm was supported by an NHMRC Fellowship
REFERENCES 1. Jorm AF, Korten AE. Assessment of cognitive decline in the elderly by informant interview. Br J Psychiatry 1988; 152: 209–13. 2. Jorm AF. A short form of the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE): Development and crossvalidation. Psychol Med 1994; 24: 145–53. 3. Barba R, Martinez-Espinosa S, Rodriguez-Garcia E, Pondal M, Vivancos J, Del Ser T. Poststroke dementia: clinical features and risk factors. Stroke 2000; 31: 1494–501. 4. Pisani MA, Inouye SK, McNicoll L, Redlich CA. Screening for preexisting cognitive impairment in older intensive care unit patients: use of proxy assessment. J Am Geriatr Soc 2003; 51: 689–93. 5. Patel P, Goldberg D, Moss S. Psychiatric morbidity in older people with moderate and severe learning disability. II: The prevalence study. Br J Psychiatry 1993; 163: 481–91. 6. Morales JM, Gonzalez-Montalvo JI, Bermejo F, Del-Ser T. The screening of mild dementia with a shortened Spanish version of the ‘Informant Questionnaire on Cognitive Decline in the Elderly.’ Alzheimer Dis Assoc Disord 1995; 9: 105–11. 7. Fuh JL, Teng EL, Lin KN et al. The Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) as a screening tool for dementia for a predominantly illiterate Chinese population. Neurology 1995; 45: 92–96. 8. Perroco T, Damin AE, Frota NA et al. Short IQCODE as a screening tool for MCI and dementia. Dement Neuropsychol 2008; 2: 300–304. 9. Jorm AF, Jacomb PA. The Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE): socio-demographic correlates, reliability, validity and some norms. Psychol Med 1989; 19: 1015–22. 10. Khachaturian AS, Gallo JJ, Breitner JC. Performance characteristics of a two-stage dementia screen in a population sample. J Clin Epidemiol 2000; 53: 531–40.
11. Cherbuin N, Anstey KJ, Lipnicki DM. Screening for dementia: a review of self- and informant-assessment instruments. Int Psychogeriatr 2008; 20: 431–58. 12. de Jonghe JF. Differentiating between demented and psychiatric patients with the Dutch version of the IQCODE. Int J Geriatr Psychiatry 1997; 12: 462–65. 13. Jorm AF, Scott R, Jacomb PA. Assessment of cognitive decline in dementia by informant questionnaire. Int J Geriatr Psychiatry 1989; 4: 35–39. 14. Morales JM, Bermejo F, Romero M, Del-Ser T. Screening of dementia in community-dwelling elderly through informant report. Int J Geriatr Psychiatry 1997; 12: 808–16. 15. Tang WK, Chan SS, Chiu HF et al. Can IQCODE detect poststroke dementia? Int J Geriatr Psychiatry 2003; 18: 706–10. 16. Jansen AP, Van Hout HP, Nijpels G et al. Self-reports on the IQCODE in Older Adults: A Psychometric Evaluation. J Geriatr Psychiatry Neurol 2008; 21: 83–92. 17. Butt Z. Sensitivity of the informant questionnaire on cognitive decline: an application of item response theory. Neuropsychol Dev Cogn B Aging Neuropsychol Cogn 2008; 15: 642–55. 18. Jorm AF, Scott R, Cullen JS, MacKinnon AJ. Performance of the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) as a screening test for dementia. Psychol Med 1991; 21: 785–90. 19. de Jonghe JF, Schmand B, Ooms ME, Ribbe MW. [Abbreviated form of the Information Questionnaire on Cognitive Decline in the Elderly]. Tijdschr Gerontol Geriatr 1997; 28: 224–29. 20. Jorm AF. The Information Questionnaire on Cognitive Decline in the Elderly (IQCODE): a review. Int Psychogeriatr 2004; 16: 275–93. 21. Isella V, Villa L, Russo A, Regazzoni R, Ferrarese C, Appollonio IM. Discriminative and predictive power of an informant report in mild cognitive impairment. J Neurol Neurosurg Psychiatry 2006; 77: 166–71. 22. Henon H, Pasquier F, Durieu I et al. Preexisting dementia in stroke patients. Baseline frequency, associated factors, and outcome. Stroke 1997; 28: 2429–36. 23. Louis B, Harwood D, Hope T, Jacoby R. Can an informant questionnaire be used to predict the development of dementia in medical inpatients? Int J Geriatr Psychiatry 1999; 14: 941–45. 24. Srikanth V, Thrift AG, Fryer JL et al. The validity of brief screening cognitive instruments in the diagnosis of cognitive impairment and dementia after first-ever stroke. Int Psychogeriatr 2006; 18: 295–305. 25. Thomas LD, Gonzales MF, Chamberlain A, Beyreuther K, Master CL, Flicker L. Comparison of clinical state, retrospective informant interview and the neurpathologic diagnosis of Alzheimer’s disease. Int J Geriatr Psychiatry 1994; 9: 233–36. 26. Rockwood K, Howard K, Thomas VS et al. Retrospective diagnosis of dementia using an informant interview based on the Brief Cognitive Rating Scale. Int Psychogeriatr 1998; 10: 53–60. 27. Jorm AF, Broe GA, Creasey H et al. Further data on the validity of the Information Questionnaire on Cognitive Decline in the Elderly (IQCODE). Int J Geriatr Psychiatry 1996; 11: 131–39. 28. Cordoliani-Mackowiak MA, Henon H, Pruvo JP, Pasquier F, Leys D. Poststroke dementia: influence of hippocampal atrophy. Arch Neurol 2003; 60: 585–90. 29. Henon H, Pasquier F, Durieu I, Pruvo JP, Leys D. Medial temporal lobe atrophy in stroke patients: relation to pre-existing dementia. J Neurol Neurosurg Psychiatry 1998; 65: 641–47.
DIAGNOSIS AND ASSESSMENT 30. Viswanathan A, Patel P, Rahman R et al. Tissue microstructural changes are independently associated with cognitive impairment in cerebral amyloid angiopathy. Stroke 2008; 39: 1988–92. 31. Klimkowicz A, Dziedzic T, Polczyk R, Pera J, Slowik A, Szczudlik A. Factors associated with pre-stroke dementia: the Cracow stroke database. J Neurol 2004; 251: 599–603. 32. Mok V, Wong A, Tang WK, Lam WW et al. Determinants of prestroke cognitive impairment in stroke associated with small vessel disease. Dement Geriatr Cogn Disord 2005; 20: 225–30. 33. Tombaugh TN, McIntyre NJ. The Mini-Mental State Examination: a comprehensive review. J Am Geriatr Soc 1992; 40: 922–35. 34. Anderson TM, Sachdev PS, Brodaty H, Trollor JN, Andrews G. Effects of sociodemographic and health variables on MiniMental State Exam scores in older Australians. Am J Geriatr Psychiatry 2007; 15: 467–76. 35. Christensen H, Jorm AF. Effect of premorbid intelligence on the Mini-Mental State and IQCODE. Int J Geriatr Psychiatry 1992; 7: 159–60. 36. Law S, Wolfson C. Validation of a French version of an informant-based questionnaire as a screening test for Alzheimer’s disease. Br J Psychiatry 1995; 167: 541–44. 37. Mulligan R, Mackinnon A, Jorm AF, Giannakopoulos P, Michel JP. A comparison of alternative methods of screening for dementia in clinical settings. Arch Neurol 1996; 53: 532–36. 38. Del-Ser T, Morales JM, Barquero MS, Canton R, Bermejo F. Application of a Spanish version of the ‘Informant Questionnaire on Cognitive Decline in the Elderly’ in the clinical assessment of dementia. Alzheimer Dis Assoc Disord 1997; 11: 3–8. 39. Bruce DG, Harrington N, Davis WA, Davis TM. Dementia and its associations in type 2 diabetes mellitus: the Fremantle Diabetes Study. Diabetes Res Clin Pract 2001; 53: 165–72. 40. Jorm AF. A short form of the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE): development and crossvalidation. Psychol Med 1994; 24: 145–53. 41. Jorm AF, Christensen H, Henderson AS, Jacomb PA, Korten AE, Mackinnon A. Informant ratings of cognitive decline of elderly people: relationship to longitudinal change on cognitive tests. Age Ageing 1996; 25: 125–29. 42. Jorm AF, Broe GACH, Sulway MR et al. Further data on the validity of the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE). Int J Geriatr Psychiatry 1996; 11: 131–39. 43. Priner M, Jourdain M, Bouche G, Merlet-Chicoine I, Chaumier JA, Paccalin M. Usefulness of the short IQCODE for predicting postoperative delirium in elderly patients undergoing hip and knee replacement surgery. Gerontology 2008; 54: 116–19. 44. Cordonnier C, Henon H, Derambure P, Pasquier F, Leys D. Influence of pre-existing dementia on the risk of post-stroke epileptic seizures. J Neurol Neurosurg Psychiatry 2005; 76: 1649–53.
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45. Henon H, Durieu I, Lebert F, Pasquier F, Leys D. Influence of prestroke dementia on early and delayed mortality in stroke patients. J Neurol 2003; 250: 10–16. 46. Pasquini M, Leys D, Rousseaux M, Pasquier F, Henon H. Influence of cognitive impairment on the institutionalisation rate 3 years after a stroke. J Neurol Neurosurg Psychiatry 2007; 78: 56–59. 47. Callahan CM, Unverzagt FW, Hui SL, Perkins AJ, Hendrie HC. Six-item screener to identify cognitive impairment among potential subjects for clinical research. Med Care 2002; 40: 771–81. 48. Ferrucci L, Del Lungo I, Guralnik JM et al. Is the telephone interview for cognitive status a valid alternative in persons who cannot be evaluated by the Mini Mental State Examination? Aging (Milano) 1998; 10: 332–38. 49. Heun R, Papassotiropoulos A, Jennssen F. The validity of psychometric instruments for detection of dementia in the elderly general population. Int J Geriatr Psychiatry 1998; 13: 368–80. 50. Nasreddine ZS, Phillips NA, Bedirian V et al. The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc 2005; 53: 695–99. 51. Swearer JM, Drachman DA, Li L, Kane KJ, Dessureau B, Tabloski P. Screening for dementia in ‘real world’ settings: The Cognitive Assessment Screening Test: CAST. Clin Neuropsychol 2002; 16: 128–35. 52. Knafelc R, Lo Giudice D, Harrigan S, Cook R, Flicker L, Mackinnon A, Ames D. The combination of cognitive testing and an informant questionnaire in screening for dementia. Age Ageing 2003; 32: 541–47. 53. Flicker L, Logiudice D, Carlin JB, Ames D. The predictive value of dementia screening instruments in clinical populations. Int J Geriatr Psychiatry 1997; 12: 203–209. 54. Senanarong V, Assavisaraporn S, Sivasiriyanonds N et al., The IQCODE: an alternative screening test for dementia for low educated Thai elderly. J Med Assoc Thai 2001; 84: 648–55. 55. Lim HJ, Lim JP, Anthony P, Yeo DH, Sahadevan S. Prevalence of cognitive impairment amongst Singapore’s elderly Chinese: a community-based study using the ECAQ and the IQCODE. Int J Geriatr Psychiatry 2003; 18: 142–48. 56. Stratford JA, LoGiudice D, Flicker L, Cook R, Waltrowicz W, Ames D. A memory clinic at a geriatric hospital: a report on 577 patients assessed with the CAMDEX over 9 years. Aust N Z J Psychiatry 2003; 37: 319–26. 57. Harwood DM, Hope T, Jacoby R. Cognitive impairment in medical inpatients. I: Screening for dementia – is history better than mental state? Age Ageing 1997; 26: 31–35. 58. Narasimhalu K, Lee J, Auchus AP, Chen CP. Improving detection of dementia in Asian patients with low education: combining the Mini-Mental State Examination and the Informant Questionnaire on Cognitive Decline in the Elderly. Dement Geriatr Cogn Disord 2008; 25: 17–22.
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Geriatric Depression Scale Meghan A. Marty, Renee Pepin, Andrea June and Daniel L. Segal University of Colorado at Colorado Springs, USA
The Geriatric Depression Scale (GDS) is a popular and well-validated screening measure for depression among older adults. It consists of 30 self-report items and is widely used in research and clinical services. This chapter provides an overview of its development, psychometric properties, alternate forms, and use with special populations.
For each of the 30 GDS items, the depressive response garners 1 point for a maximum total of 30 points. Regarding general cutoffs, total scores ranging from 0 to 9 indicate normal mood; scores ranging from 10 to 19 indicate mild depressive symptoms, and scores ranging from 20 to 30 indicate severe depressive symptoms. The measure is free to use and in the public domain. It can be accessed at www.stanford.edu/∼yesavage/GDS.html.
DEVELOPMENT, ADMINISTRATION AND SCORING The GDS was developed to address the limited applicability of existing depression scales with older adults1,2 . One such problem with scales that were developed and validated with younger populations relates to somatic complaints. Though somatic complaints can be a useful indicator of depression in younger samples, it is common for older adults to report somatic problems that can skew the sensitivity and specificity of a screen where older adults are more likely to have false positive depression scores. As such, the GDS does not include many somatic components in the scale and also consists of questions that are appropriate for the ageing population both in content and format. Initially, 100 questions were selected by researchers and clinicians with geriatric experience and administered to both non-depressed and depressed older adults. Of the original 100 items, the 30 items that correlated most highly with the total score were included in the final scale. The scale was designed so that it could be administered easily in a self-rating format that would not be cumbersome for patients or medical personnel2 . Most individuals complete the GDS in under 10 minutes. The GDS has a forced-choice response format where individuals are asked to respond yes or no to each item. However, some patients have problems with the yes/no dichotomy, instead preferring to answer ‘sometimes’ by either writing it in or by circling the space between the yes and no responses, though neither is a scored answer. It can help if explicit instructions are provided to patients to respond to each item in the way that best answers the question. In the initial validation study, the examiner read the items orally and recorded responses for individuals who could not complete the form without assistance. However, later studies found significant differences between mean scores for self-administered and staff-administered modes of presentation, with higher scores reported for self-administered scales3,4 . There is no significant difference between scores of a card-based administration and verbal administration of the GDS5 .
PSYCHOMETRIC PROPERTIES Reliability The GDS has been shown to be internally consistent and reliable over time. In the original reliability study, split-half and alpha coefficients were both 0.942 . Other studies have demonstrated similar findings with diverse populations, showing alpha and split-half coefficients ranging from 0.80 to 0.996 – 8 . Several studies have examined reliability of scores over time, finding high test–retest correlations between 0.85 and 0.942,7 – 9 .
Validity An important psychometric property of a depression screen is its ability to differentiate between depressed and non-depressed individuals (i.e. criterion validity). The sensitivity of the GDS refers to its ability to correctly identify individuals who are depressed whereas the specificity refers to its ability to correctly identify those individuals who are not depressed. Brink et al.1 found an 84% sensitivity rate and a 95% specificity rate for the GDS among community-dwelling older adults. Several other studies have examined the sensitivity and specificity of the GDS with diverse populations, finding acceptable levels above 80%. These have included medical patients, stroke patients, individuals suffering from dementia, nursing home residents, and psychiatric inpatients (for a thorough review, see Stiles and McGarrahan10 ). The correlation between the GDS and other screening measures for depression is an indicator of the scale’s construct validity. The GDS was initially validated against the Hamilton Rating Scale for Depression11 (HRS-D) and the Zung Self-Rating Depression Scale12 (SDS), finding high correlations suggesting that the GDS measures similar constructs as the HRS-D and SDS. Other comparisons with the GDS have also been conducted, including the Beck Depression
Principles and Practice of Geriatric Psychiatry, 3rd edn. Edited by Mohammed T. Abou-Saleh, Cornelius Katona and Anand Kumar 2011 John Wiley & Sons, Ltd
DIAGNOSIS AND ASSESSMENT Inventory13 (BDI) and the Center for Epidemiological Studies Depression Scale14 (CES-D). These comparisons also yielded significant correlations, adding to evidence supporting the construct validity of the GDS15 – 18 . Furthermore, the GDS has non-significant correlations with measures of cognition, adding to the empirical evidence that the GDS measures depression and not another construct19 – 21 .
Dimensionality Factor studies on the 30 items of the GDS have yielded mixed results. Sheikh et al.22 proposed a five-factor solution among communitydwelling older adults. Abraham and colleagues23 proposed a sixfactor solution among nursing home residents. These studies contrast the findings from Parmelee et al.9 and Salamero and Marcos24 , which both found the GDS items to be highly intercorrelated and suggested the scale has only one factor. Based on these results, both advised the GDS should only be interpreted from a single total score.
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into a two-tiered instrument, named the GDS-5/15, so that the full GDS-15 would only be administered to individuals who scored a 2 or greater on the initial GDS-5 items37 . Many brief forms of the GDS have been compared to a single-item depression screen. For example, D’Ath et al.27 created three versions of the GDS containing 10 items, 4 items, or 1 item (‘Do you feel that your life is empty?’). While the 10-item form performed well using either 2/3 or 3/4 cut-off scores, the 4- and 1-item versions had low sensitivity and specificity. Hoyl et al.34 found a single-item depression screen (‘Do you often feel sad or depressed?’) performed significantly worse than the 15- and 5-item GDS, with a sensitivity of 85% and specificity of 65%. Likewise, a comparison of different versions of the GDS in a Dutch population found the diagnostic value of 30-, 15-, 10- and 4-item scales did not differ significantly; however, the 1-item version performed no better than chance38 . Almeida and Almeida39 determined the 15- and 10-item scales were good screening instruments for depression in a Brazilian population, but cautioned against using 4- and 1-item forms because of low reliability and failure to show severity of depressive episodes.
ALTERNATE FORMS Brief Forms
Nursing Home Forms
Several brief forms of the GDS have been designed for use in settings where time is limited for depression assessment and with frail individuals for whom fatigue and poor concentration are concerns. Sheikh and Yesavage25 developed a 15-item version of the GDS, commonly referred to as the Short Form (GDS-SF), by taking the 15 items from the original scale that had the highest correlation with depressive symptoms in earlier studies. Findings from their validation study suggested both forms were highly correlated (r = 0.84) and effectively differentiated depressed from non-depressed individuals. A subsequent study reported cut-off scores for the GDS-15 as normal (0–4), mild (5–9) and moderate to severe (10–15)26 . Older adults rated the GDS-15 as an acceptable measure that was not difficult or stressful to complete27 . Evidence for the validity of the GDS-15 is mixed. Some studies suggest the GDS-15 is not a suitable substitute for the full scale GDS in community-dwelling older adults26,28 or cognitively impaired individuals29 . It does appear effective for screening depression in older adults who are cognitively intact and medically ill29 , have affective disorders30 , or who are seen in primary care clinics27,31 . The GDS-15 was shown to consistently identify depressed individuals in a VA nursing home population32 . Chiang and colleagues33 suggest that the GDS-15 may be less effective as a screening tool, but that it could be most effectively used to detect changes in moderate levels of depression. Hoyl and colleagues34 developed a five-item GDS for use in a geriatric outpatient population by selecting items from the GDS-15 that had the highest correlation with a clinical diagnosis of depression. Using a score of 2 or greater to indicate possible depression, the GDS-5 had a sensitivity of 97%, specificity of 85%, and alpha coefficient of 0.80. The GDS-5 was found to be as effective as the GDS-15 in an Italian sample of cognitively intact older adults across three settings: a geriatric acute care ward, a geriatric outpatient clinic and a nursing home35 . In addition, validity of the GDS-5 has been demonstrated for older sedentary adults.36 Weeks and colleagues37 compared two versions of four-item GDS measures and the GDS-5 to the GDS-15 in a sample of acute care patients. They found the GDS-5 showed the highest sensitivity (97%), but led to a high number of false positives. The researchers re-ordered the GDS-15 items
A 12-item GDS was created for use with individuals living in residential care settings, including those with cognitive impairment (GDS12R)40 . During administration of the longer GDS in residential care facilities, interviewers found difficulties with a few of the items that appeared irrelevant or ambiguous to residents (e.g. ‘Do you prefer staying in rather than going out and doing new things?’). Removal of these items increased internal reliability from 0.76 to 0.81, with no significant difference in internal reliability for those with cognitive impairment. A cut-off score of 4/5 maximized both sensitivity and specificity of the GDS-12R and was suggested for research purposes. A cut-off of 3/4 was suggested for clinical use40 . Similarly, Jongenelis et al.41 developed a version of the GDS that would be more user-friendly for nursing home residents. Clinical experts (a psychologist, a physician and a nurse) reviewed and rated the usefulness of the items of the GDS-15, eliminating seven items that were presumed to be offensive or confusing to nursing home residents. The eight-item instrument demonstrated high internal consistency (alpha coefficient of 0.80) with equal sensitivity (96.3%) and greater specificity than the GDS-15 (71.7% versus 63.3%) at a cut-off point of 2/3. They concluded that although the GDS was created for older adults, it was not necessarily designed for frail nursing home residents and alternate versions perform better with this specific population41 .
Collateral Forms Nitcher et al.42 created a 30-item Collateral Source Geriatric Depression Scale (CS-GDS) by simply changing the pronouns from you to they on the original GDS items. Patients with cognitive functioning ranging from normal to moderate dementia and an informant with extensive personal knowledge about the patient completed a self-report version of the GDS-30 and the CS-GDS respectively. Informants reported a higher frequency of symptomatic responses for all symptoms, but both versions were consistent with an independent diagnosis of depression. Correlations between the CS-GDS and the GDS varied by familial relation, ranging from 0.55 for sons to 0.32 for daughters-in-law. A cut-off score of 21 maximized sensitivity and specificity (both at 68%). In addition, the CS-GDS has been shown
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to maintain adequate reliability and validity when administered via telephone, using a cut-off score of 1943 . Brown and Schinka44 developed a 15-item informant version of the GDS (GDSI-15) for use as an adjunctive measure to self-report versions of the GDS or as an independent measure of depression. Cognitively intact older adults and an informant completed a selfreport version of the GDS-30 and the 30-item CS-GDS, respectively. Item characteristics for all 30 items of the CS-GDS were examined; the same items used in the original version of the GDS-15 were found to have the best scale characteristics for the shortened informant version. Consistent with findings from the CS-GDS, informant scores were significantly higher than patient scores and had a 0.55 correlation with the self-report GDS-15. A cut-off score of 5 for the GDSI-15 was found to be optimal44 .
Some authors54,55 propose shifting the cut-off score (between 4 and 6) when using the GDS with a cognitively impaired individual.
USE WITH SPECIAL POPULATIONS
Oldest-Old Individuals
Long-Term Care
De Craen et al.59 examined the sensitivity and specificity of the GDS15 in adults aged 85 years and older. Results indicated a low cutoff point (2/3) had high sensitivity (100%) and adequate specificity (68%). Findings from another study with adults aged 85 and older demonstrated that the GDS was able to detect increases in depressive symptoms after negative life events such as the loss of a spouse60 . This suggests that the GDS is an appropriate measure to use for assessing longitudinal changes in older adults. A comparison between the GDS-15 and the General Health Questionaire-1261 (GHQ-12) in Chinese old-old adults found the GDS-15 had higher reliability and higher sensitivity62 .
The GDS has been shown to be a reliable and valid instrument for identifying depressed nursing home residents8,45,46 . Abraham et al.23 demonstrated that the factor structure of the GDS represents six common facets of depression in nursing home residents: life dissatisfaction, dysphoria, hopelessness/decreased self-attitude, rumination/anxiety, social withdrawal/decreased motivation, and decreased cognition. Compared to a visual analogue scale, which required participants to mark their level of depression on a line, the GDS was better able to predict ratings of depression by a psychologist, particularly with residents with better cognitive functioning47 . These researchers slightly modified four items of the GDS to be tailored to nursing home residents. Heiser48 found the GDS was better at detecting depression in nursing home residents than the Minimum Data Set. Targeting the concern of nursing home residents being too frail to complete a multiple item scale, Jongenelis et al.49 evaluated the diagnostic accuracy of the GDS (30-, 15-, 12-, 10-, 5-, 4- and 1-item versions) among nursing home residents. Scales with greater than or equal to four items were useful for screening depression, but scales with lower numbers of items had less specificity. That is, scales with 4 items were able to detect major depression, but 10 items were necessary to effectively detect milder depression. In a similar study, researchers50 examined various versions of the GDS (30-, 15- and 8-item) and compared them to the Montgomery Asberg Depression Rating Scale (MADRS)51 . Using the same data set utilized in the study by Jongenelis et al.41 mentioned previously, not surprisingly, the authors found a similar pattern of results from the various forms of the GDS. They found the GDS was preferable to the MADRS due to the ease of administration; however, the MADRS, a longer instrument, was superior to all GDS versions in detecting depression in nursing home residents.
Cognitive Impairment Several studies suggest that the accuracy of the GDS decreases as the level of cognitive impairment increases29,47,52 – 54 . The majority of these authors (with the exception of Burke et al.52 ) suggest that the GDS can be used with older adults with mild to moderate cognitive impairment. A more preferable type of screen may involve the reporting of a collateral source such as the Cornell Scale for Depression in Dementia54 (CSDD) or the informant versions of the GDS.
Primary Care A large study56 of older adult primary care patients found the GDS to be reliable and valid in this population. A systematic review57 of nine studies of the GDS in primary care settings found high sensitivity (ranging from 79% to 100%) and adequate specificity (ranging from 67% to 80%). Bijl et al.31 examined the cut-off score of 5 in primary care patients and reported adequate sensitivity (79%) and specificity (67%). These positive results suggest that use of the GDS provides reliable and accurate depression screening in primary care settings58 .
Ethnic Groups The GDS has been evaluated in several different ethnic groups both within and outside of the US, with mixed results. It has shown to be a satisfactory screening tool in Chinese63 , Portuguese64 , Iranian65 and Japanese American older adults66 . Results from a study comparing Korean and American older adults indicated the GDS-SF had good reliability with both groups, but the underlying factor structure differed67 . Costa and colleagues68 found that reliability was good for the GDS, but it did not perform better than the GHQ-1261 and neither was an ideal screening tool for Brazilian older adults even with adjustment of cut-off scores.
SUMMARY Use of the GDS for the screening and detection of depression among older adults is widespread. As with any psychological measure, test performance of the GDS varies depending upon population characteristics (e.g. individuals with different levels of cognitive functioning). Brief forms of the GDS, as well as versions designed for specific populations (e.g. residents in nursing homes), detect depressive symptoms as well as, if not better than, the original GDS. Further research is needed to explore the factor structure of the GDS. The GDS remains a popular and well-validated screening tool for diverse older adult clinical and research settings.
REFERENCES 1. Brink TL, Yesavage JA, Lum O et al. Screening tests for geriatric depression. Clin Gerontol 1982; 1: 37–44.
DIAGNOSIS AND ASSESSMENT 2. Yesavage JA, Brink TL, Rose TL et al. Development and validation of a geriatric depression screening scale: a preliminary report. J Psychiatr Res 1983; 17: 37–49. 3. Cannon BJ, Thaler T, Roos S. Oral versus written administration of the Geriatric Depression Scale. Aging Ment Health 2002; 6: 418–22. 4. O’Neill D, Rice I, Blake P, Walsh JB, Coakley D. The Geriatric Depression Scale: rater-administered or self-administered? Int J Geriatr Psychiatry 1992; 7: 511–15. 5. Brewer L, Connolly R, Smith D, O’Neill D. The Geriatric Depression Scale: feasibility of cardbased-administration. Ir J Psychol Med 2002; 19: 132. 6. Agrell B, Dehlin O. Comparison of six depression rating scales in geriatric stroke patients. Stroke 1989; 20: 1190–94. 7. Brink TL, Curran P, Dorr ML et al. Geriatric Depression Scale reliability: order, examiner, and reminiscence effects. Clin Gerontol 1985; 3: 57–60. 8. Lesher EL. Validation of the Geriatric Depression Scale among nursing home residents. Clin Gerontol 1986; 4: 21–8. 9. Parmelee PA, Lawton MP, Katz IR. Psychometric properties of the Geriatric Depression Scale among the institutionalized aged. J Consult Clin Psychol 1989; 1: 331–8. 10. Stiles PG, McGarrahan PF. The Geriatric Depression Scale: a comprehensive review. J Clin Geropsychol 1998; 4: 89–110. 11. Hamilton M. A rating scale for depression. J Neurol Neurosurg Psychiatry 1960; 23: 56–62. 12. Zung WWK. A self-rating depression scale. Arch Gen Psychiatry 1965; 12: 63–70. 13. Beck A, Ward C, Mendelson M, Mock J, Erbaugh J. An inventory for measuring depression. Arch Gen Psychol 1961; 4: 561–71. 14. Radloff LS. The CES-D scale: a self-report depression scale for research in the general population. Appl Psychol Meas 1977; 1: 385–401. 15. Brink TL, Niemeyer L. Assessment of depression in college students: Geriatric Depression Scale versus Center for Epidemiological Studies Depression Scale. Psychol Rep 1992; 71: 163–6. 16. Hickie C, Snowdon J. Depression scales for the elderly: GDS, Gilleard, Zung. Clin Gerontol 1987; 6: 51–3. 17. Hyer L, Blount J. Concurrent and discriminant validities of the Geriatric Depression Scale with older psychiatric patients. Psychol Rep 1984; 54: 611–16. 18. Norris JT, Gallagher DE, Wilson A, Winograd CH. Assessment of depression in geriatric medical outpatients: the validity of two screening measures. J Am Geriatr Soc 1987; 35: 989–95. 19. Feher EP, Larrabee GJ, Cook TH. Factors attenuating the validity of the Geriatric Depression Scale in a dementia population. J Am Geriatr Soc 1992; 40: 906–9. 20. Parmelee P, Katz IR, Lawton MP. The relation of pain to depression among institutionalized aged. J Gerontol A Biol Sci Med Sci 1991; 46: P15–21. 21. Rapp SR, Parisi SA, Walsh DA, Wallace CE. Detecting depression in elderly medical inpatients. J Consult Clin Psychol 1988; 56: 509–13. 22. Sheikh JI, Yesavage JA, Brooks JO, III et al. Proposed factor structure of the Geriatric Depression Scale. Int Psychogeriatr 1991; 3: 23–8. 23. Abraham IL, Wofford AB, Lichtenberg PA, Holroyd S. Factor structure of the Geriatric Depression Scale in a cohort of depressed nursing home residents. Int J Geriatr Psychiatry 1994; 9: 611–17.
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24. Salamero M, Marcos T. Factor study of the Geriatric Depression Scale. Acta Psychiatr Scand 1992; 86: 283–6. 25. Sheikh JI, Yesavage JA. Geriatric Depression Scale (GDS): recent evidence and development of a shorter version. Clin Gerontol 1986; 5: 165–73. 26. Alden D, Austin C, Sturgeon R. A correlation between the Geriatric Depression Scale long and short forms. J Gerontol B Psychol Sci Soc Sci 1989; 44: 124–5. 27. D’Ath P, Katona P, Mullan E, Evans S, Katona C. Screening, detection and management of depression in elderly primary care attenders. I: The acceptability and performance of the 15 item Geriatric Depression Scale (GDS15) and the development of short versions. Fam Pract 1994; 11: 260–66. 28. Ingram F. The short Geriatric Depression Scale: a comparison with the standard form in independent older adults. Clin Gerontol 1996; 16: 49–56. 29. Burke WJ, Roccaforte WH, Wengel SP. The short form of the Geriatric Depression Scale: a comparison with the 30-item form. J Geriatr Psychiatry Neurol 1991; 4: 173–8. 30. Herrmann N, Mittmann N, Silver IL et al. A validation study of the Geriatric Depression Scale short form. In J Geriatr Psychiatry 1996; 11: 457–60. 31. Bijl D, van Marwijk HWJ, Ad`er HJ, Beekman ATF, de Haan M. Test-characteristics of the GDS-15 in screening for major depression in elderly patients in general practice. Clin Gerontol 2005; 29: 1–9. 32. Aikman GG, Oehlert ME. Geriatric Depression Scale: long form versus short form. Clin Gerontol 200; 22: 63–70. 33. Chiang KS, Green KE, Cox EO. Rasch analysis of the Geriatric Depression Scale-Short Form. Gerontologist 2009; 49: 262–75. 34. Hoyl MT, Alessi CA, Harker JO et al. Development and testing of a five-item version of the Geriatric Depression Scale. J Am Geriatr Soc 1999; 47: 873–8. 35. Rinadli P, Mecocci P, Benedetti C et al. Validation of the fiveitem Geriatric Depression Scale in elderly subjects in three different settings. J Am Geriatr Soc 2003; 51: 694–8. 36. Marquez DX, McAuley E, Motl RW et al. Validation of the Geriatric Depression Scale-5 scores among sedentary older adults. Educ Psychol Meas 2006; 66: 667–5. 37. Weeks SK, McGann PE, Michaels TK, Penninx BWJH. Comparing various short-form Geriatric Depression Scales leads to the GDS-5/15. J Nurs Scholarsh 2003; 35: 133–7. 38. van Marwijk HWJ, Wallace P, de Bock GH et al. Evaluation of the feasibility, reliability, and diagnostic value of shortened versions of the Geriatric Depression Scale. Br J Gen Pract 1995; 45: 195–9. 39. Almeida OP, Almeida SA. Short versions of the Geriatric Depression Scale: a study of their validity for the diagnosis of a major depressive episode according to the ICD-10 and DSM-IV. Int J Geriatr Psychiatry 1999; 14: 858–65. 40. Sutcliffe C, Cordingley L, Burns A et al. A new version of the Geriatric Depression Scale for nursing and residential home populations: the Geriatric Depression Scale (Residential) (GDS12R). Int Psychogeriatr 2000; 12: 173–81. 41. Jongenelis K, Gerritsen DL, Pot AM et al. Construction and validation of a patient- and user-friendly nursing home version of the Geriatric Depression Scale. Int J Geriatr Psychiatry 2007; 22: 837–42. 42. Nitcher RL, Burke WJ, Roccaforte WH, Wengel SP. A collateral source version of the Geriatric Depression Rating Scale. Am J Geriatr Psychiatry 1993; 1: 143–52.
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43. Burke WJ, Rangwani S, Roccaforte WH et al. The reliability and validity of the collateral sources version of the Geriatric Depression Rating Scale administered by telephone. Int J Geriatr Psychiatry 1997; 12: 288–94. 44. Brown LM, Schinka JA. Development and initial validation of a 15-item informant version of the Geriatric Depression Scale. Int J Geriatr Psychiatry 2005; 20: 911–18. 45. Gerety MB, Williams JW, Mulrow CD et al. Performance of case-finding tools for depression in the nursing home: influence of clinical and functional characteristics and selection of optimal threshold scores. J Am Geriatr Soc 1994; 42: 1103–9. 46. Soon JA, Levine M. Screening for depression in patients in longterm care facilities: a randomized controlled trial of physician response. J Am Geriatr Soc 2002; 50: 1092–9. 47. Snowdon JS, Lane F. Use of Geriatric Depression Scale by nurses. Aging Ment Health 1999; 3: 227–33. 48. Heiser D. Depression identification in the long-term care setting: the GDS vs. the MDS. Clin Gerontol 2004; 27: 3–18 49. Jongenelis K, Pot AM, Eisses AMH et al. Diagnostic accuracy of the original 30-item and shortened versions of the Geriatric Depression Scale in nursing home patients. Int J Geriatr Psychiatry 2005; 20: 1067–74. 50. Smalbrugge M, Jongenelis L, Pot AM, Beekman ATF, Eefsting JA. Screening for depression and assessing change in severity of depression. Is the Geriatric Depression Scale (30-, 15- and 8item versions) useful for both purposes in nursing home patients? Aging Ment Health 2008; 2: 244–8. 51. Montgomery SA, Asberg M. A new depression scale designed to be more sensitive to change. Br J Psychiatry 1979; 143: 382–9. 52. Burke WJ, Houston MJ, Boust SJ, Roccaforte WH. Use of the Geriatric Depression Scale in dementia of the Alzheimer type. J Am Geriatr Soc 1989; 37, 856–60. 53. Debruyne H, Van Buggenhout M, Le Bastard N et al. Is the geriatric depression scale a reliable screening tool for depressive symptoms in elderly patients with cognitive impairment? Int J Geriatr Psychiatry 2009; 24: 556–62. 54. Kørner A, Lauritzen L, Abelskov K et al. The Geriatric Depression Scale and the Cornell Scale for Depression in Dementia. A validity study. Nord J Psychiatry 2006; 60: 360–64. 55. Schreiner AS, Hayakawa H, Morimoto T, Kakuma T. Screening for late life depression: cut-off scores for the Geriatric Depression Scale and the Cornell Scale for Depression in Dementia among Japanese subjects. Int J Geriatr Psychiatry 2003; 18: 498–505.
56. Friedman B, Heisel MJ, Delavan RL Psychometric properties of the 15-item Geriatric Depression Scale in functionally impaired, cognitively intact, community-dwelling elderly primary care patients. J Am Geriatr Soc 2005; 53: 1570–76. 57. Watson LC, Pignone MP. Screening accuracy for late-life depression in primary care: a systematic review. J Fam Pract 2003; 52: 956–64. 58. Peach J, Koob JJ, Kraus MJ. Psychometric evaluation of the Geriatric Depression Scale (GDS): supporting its use in health care settings. Clin Gerontol 2001; 23: 57–67. 59. de Craen AJM, Heeren TJ, Gussekloo J. Accuracy of the 15-item Geriatric Depression Scale (GDS-15) in a community sample of the oldest old. Int J Geriatr Psychiatry 2003; 18: 63–6. 60. Vinkers, DJ, Gussekloo J, Stek ML, Westendorp RGJ, van der Mast RC. The 15-item Geriatric Depression Scale (GDS-15) detects changes in depressive symptoms after a major negative life event. The Leiden 85-plus study. Int J Geriatr Psychiatry 2004; 19: 80–84. 61. Goldberg DP. Detection of Psychiatric Illness by Questionnaire. London: Oxford University Press, 1972. 62. Boey KW, Chiu HFK. Assessing psychological well-being of the old-old: a comparative study of GDS-15 and GHQ-12. Clin Gerontol 1998; 19: 65–75. 63. Boey KW. The use of the GDS-15 among the older adults in Beijing. Clin Gerontol 2000; 21: 49–75. 64. Pocinho MTS, Farate C, Dias CA, Lee TT, Yesavage JA. Clinical and psychometric validation of the Geriatric Depression Scale (GDS) for Portuguese elders. Clin Gerontol 2009; 32: 223–36. 65. Malakouti SK, Fatollahi P, Mirabzadeh A, Salavati M, Zandi T. Reliability, validity, and factor structure of the GDS-15 in Iranian elderly. Int J Geriatr Psychiatry 2006; 21: 588–93. 66. Iwamasa GY, Hilliard KM, Kost CR. The Geriatric Depression Scale and Japanese American older adults. Clin Gerontol 1998; 19: 13–24. 67. Jang Y, Small BJ, Haley WE. Cross-cultural comparability of the Geriatric Depression Scale: comparison between older Koreans and older Americans. Aging Ment Health 2001; 5: 31–7. 68. Costa E, Barreto SM, Uchoa E et al. Is the GDS-30 better than the GHQ-12 for screening depression in elderly people in the community? The Bambui health aging study (BHAS). Int Psychogeriatr 2006; 18: 493–503.
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Dementia Care Mapping Dawn Brooker University of Worcester Association for Dementia Studies, Institute of Health and Society, University of Worcester, Worcester, UK
INTRODUCTION Dementia Care Mapping (DCM)1,2 is an observational tool that has been used in formal dementia care settings such as hospital wards, care homes and day care facilities since 1991. Its main uses are:
• at an individual clinical level to elucidate situations where an individual is displaying distress behaviours or to improve well-being;
• as an instrument of practice development for shifting the culture of care to one that is person-centred rather than task focused;
• as a tool in research to assess quality of care and quality of life. DCM is grounded in the theoretical perspective of a person-centred approach to dementia care. Person-centred care values all people regardless of age and health status, is individualized, emphasizes the perspective of the person with dementia and stresses the importance of relationships3 . DCM originated from the pioneering work of the late Professor Tom Kitwood in person-centred approaches to dementia care. In his final book4 Kitwood described DCM as: ‘a serious attempt to take the standpoint of the person with dementia, using a combination of empathy and observational skill’ (p. 4).
THE DEVELOPMENT OF DCM Tom Kitwood and his PhD student Kathy Bredin developed the original tool through ethological observations of many hours in nursing homes, hospital facilities, and day care facilities in the United Kingdom1 . It was designed primarily as a tool to develop personcentred care practice over time with data being fed back to care teams who could then use it to improve their practice. The original development work is not available in the public domain5 . DCM has been through a number of changes since its inception. From 1991 to 1997, the first publically available version, DCM 6th edition, was used. This was revised based on feedback from practitioners in the UK resulting in the 7th edition being launched in 1997. The unexpected death of Tom Kitwood in 1998 created a need to have more formalized structures around DCM. The role of strategic lead for DCM was created at the University of Bradford in 2001 which the author fulfilled until 2009. The formal network of DCM trainers and the DCM International Implementation Group had their inaugural meetings in 2001 and 2002 respectively. DCM underwent a further major revision 2002–2004 drawing on the international per-
spectives. In 2005 DCM 8 was launched. The revised tool (DCM 8) was validated against DCM 7th edition6 . The DCM tool is only available through undertaking a registered courses delivered by licensed trainers using standardized training methods. Those undertaking the basic DCM training course (3–4 days duration) do not need any formal qualification although the complexity of the method requires reasonable numeracy and literacy skills. DCM is not aligned to a particular discipline. There are a number of different levels of training that have developed over the years to equip users of DCM at a variety of different levels. DCM training has been available in the UK since 1991. The worldwide spread of DCM has been remarkable. Tom Kitwood taught the first DCM course outside the United Kingdom in the United States in 1998. In the same year, the materials were translated into German and training commenced there. Australia ran its first course in 2001. The Danish translation and the first course in Denmark took place in 2002. Training has been available in Switzerland with support from Germany since 2002. The materials were translated into Japanese and the first basic course took place in Japan in 2003. Translation into Korean occurred a couple of years later. Spanish and Catalan translations were completed in 2009. At the time of going into press the translations into Flemish, Dutch and Italian are being done. Strategic partnerships exist between the University of Bradford and organizations in all these countries to ensure that training in DCM adheres to international quality standards. At time of going into press there are approximately 8000 people trained at basic level worldwide. The DCM International Implementation Group is an association of all those countries where DCM training is offered or who are preparing to offer training. Its purpose is to consider the training, care practice and research associated with DCM drawing on expertise from around the world and ensuring a common set of quality standards. DCM has grown in popularity over the years. Many practitioners have used DCM in many different situations and continue to do so. This may be because DCM appears to provide a vehicle for those wishing to systematically move dementia care from primarily a custodial and task-focused model into one that focuses on the wellbeing of people living with dementia. There are very few other tools that purport to do this or that have been shown to be effective in this endeavour. Whether it has had a sustained impact on practice is difficult to assess. The investment of time and effort in undertaking training and sustaining mapping cycles can be a barrier in practice.
Principles and Practice of Geriatric Psychiatry, 3rd edn. Edited by Mohammed T. Abou-Saleh, Cornelius Katona and Anand Kumar 2011 John Wiley & Sons, Ltd
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There has been no survey of how many care providers actually use DCM in practice. A survey undertaken some years ago indicated that around 50% of people undertaking the training actually used mapping in practice although many more reported a beneficial impact on their own practice of undertaking the training7 .
THE DCM TOOL During a DCM evaluation, an observer (mapper) tracks five people with dementia (participants) continuously over a representative time period. Observation takes place in communal areas of care facilities. Guidelines are provided during training about how to observe in a way that does not increase the ill-being of people with dementia. After each 5-minute period (a time frame) two types of codes are used to record what has happened to each individual. The behavioural category code (BCC) describes one of 23 different domains of participant behaviour that has occurred. Based on behavioural indicators, a judgement is also made of the relative state of affect and engagement experienced by the person with dementia. This is called a mood/engagement value (ME value) and is rated on a scale ranging from −5 (extreme negative state) to +5 (extreme positive state. ME values are averaged over the mapping period to arrive at a well- and ill-being score (WIB score). This provides an index of relative well-being for a particular time period for an individual or a group. Being in a state of well-being is defined as experiencing a preponderance of positive over negative experiences and feelings over a period of time. Therefore, for a person with dementia, experiencing relative well-being would relate to experiencing more of the indicators of well-being over a period of time than the indicators of ill-being. Personal detractions (PDs) and personal enhancers (PEs) are recorded whenever they occur. PDs are staff behaviours that have the potential to undermine the personhood of those with dementia. These are described and coded according to type and severity. PEs are staff behaviours that are thought to enhance personhood. These are described and coded according to type and the degree to which it is thought they enhance personhood. From published papers on DCM8 there is consistency of what is reported in DCM data. In long-term care facilities, behaviour codes indicating social interaction, passive watching, and eating and drinking appear as the most frequent codes almost without exception. Codes for walking and sleeping appear as the next most frequently cited. In facilities with lower well-being scores, withdrawn and repetitive behaviours are frequently seen. In facilities with higher wellbeing scores, creative activity, physical exercise and general leisure activities occur more frequently. Generally, a greater diversity of behaviour and higher well-being scores are reported in day-care facilities. These scores both increase generally during periods of therapeutic activity. Higher levels of personal detractions occur in those facilities with the lowest well-being scores.
LENGTH OF OBSERVATION PERIOD Most of the published studies here have mapped continuously for 6 hours, although those using DCM for practice-development purposes mapped for longer9 – 12 . It also is evident from practice that useful insights can be gained from mapping for just a couple of hours13 . Mapping an individual at a particular time of day may throw light on the causes and triggers of distress behaviours. Length of maps will depend, in part, on the reason for mapping. Sometimes mapping
is spread over a couple of days. This can have the advantage of sampling a greater amount of variety of staffing situations but some of the continuity may be lost at an individual participant level. For research purposes, a statistically significant correlation between the hour prior to lunch and a 6-hour map on all their key indicators at the group level has been described14 . It is likely that there would be more variation for individual level data. Maps above 4 hours’ duration have been reported to correlate well with longer maps but that those below 4 hours do not6 . When comparing maps over time it is important to try to map for the same time period to ensure that the same opportunities are available for activity on both occasions. Mapping over a meal time will increase levels of activity for example. So if on the first occasion of mapping, only one meal time is observed it is important to ensure only one meal time is observed on the second occasion.
WHAT DCM EVALUATES The DCM tool provides in-depth detail about the following:
• variations in individual and group care facility levels of well-being and ill-being;
• how people with dementia spend their time and how this is linked to relative well- and ill-being; and
• staff behaviour that promotes personhood and staff behaviours that undermine personhood. DCM tells us about the quality of care as it impacts on the quality of life of those living in dementia care settings. Within Kitwood’s writing was the assumption that, for people with dementia, wellbeing is a direct result of the quality of relationships they enjoy with those around them. The interdependency of the quality of the care environment to the relative quality of life experienced by people with dementia is central to person-centred care practice. In placing DCM in the taxonomy of measures of quality of life and quality of care, DCM attempts to measure elements of both. In its BCCs and WIBs, DCM measures relative well-being, affect, engagement and occupation, which are important elements of quality of life. Through PDs and PEs, DCM records the quality of care practice as it promotes or undermines the personhood of those being mapped. In terms of concurrent validity with other measures there is some evidence that DCM is related to indicators of quality of care9,15 and with proxy quality-of-life measures14,16 . With persons with more advanced dementia it is difficult to ascertain whether there is a correlation between DCM scores and direct quality-of-life interviews. One study16 did not find a correlation on a subsample with participants with mild cognitive impairment. In a multi-method study17 it was noted that during interviews, people with dementia rated their quality of life as better than their DCM scores would suggest. DCM measures something similar to proxy measures and other observation measures. It is somewhat different from other qualityof-life and quality-of-care measures in that it attempts to measure elements of both. In training to use DCM, mappers are explicitly taught to increase their empathy for the viewpoint of the person with dementia and to use this during their coding decisions.
RELIABILITY OF DCM In research papers it appears that a reasonable agreement between trained mappers can be achieved. Nineteen studies reported inter-rater
DIAGNOSIS AND ASSESSMENT coding agreements ranging from 0.7 to 1.0, most reporting concordance coefficients of 0.88 . Mappers in routine practice are likely not to spend time ensuring that their inter-rater reliability is adequate. When many different mappers are engaged in mapping at different points in time, drifts in coding can have a significant impact on results18 unless systematic checking is in place to prevent this. There are various ways in which reliability can be achieved in routine mapping19 . Only one paper has reported on test–retest reliability on the same individuals a week apart14 . There was satisfactory correlation between +3 and +5 ME values, overall WIB score and type of BCC. To date DCM data has only been published on DCM 7 data.
POPULATIONS THAT DCM IS USED WITH DCM is used primarily with people with dementia living in longterm care settings. This covers a wide range of cognitive ability and dependence. There is evidence to suggest that level of dependency is correlated with DCM scores, specifically that low WIB scores are associated with high dependency levels9,16,18 . However, this is not always the case20,21 . The correlations between low WIB scores and high dependency may of course be related to a third factor of poorer quality of psychosocial care for people with dementia who have high dependency needs. In two studies where DCM was used in a systematic way to improve practice over time, the relationship between dependency and WIB scores disappeared as care quality improved9,10 . DCM helps to focus care staff to consider the needs of those whose well-being is lowest, who are usually those with the greatest levels of dependency. Accordingly, DCM can help staff to refocus and adapt their care practices to better meet the needs of more dependent clients. The evidence that dependency level skews DCM results is strong enough to suggest that a measure of dependency should be routinely taken alongside DCM evaluations so that the results can be scrutinized for this relationship. Although DCM was originally developed in formal care services for people living with dementia, over the years it has also been used in services for people with learning disabilities22 on general elderly care wards23 and with people with Huntington’s disease24 .
USING DCM TO IMPROVE THE QUALITY OF CARE DCM lends itself well to improving well-being and quality of life for people with dementia at an individual care-plan level. The analysis of individual maps provides a lot of information about how to optimize an individual’s well-being over the day. Small things that engender joy or distress, that are easy to miss as part of general care, become very clear in the process of mapping. This can be built upon to ensure that people have the opportunity to experience well-being more often. At a group level, for example in the management of a hospital ward or nursing home, DCM can be used to improve the organization of care towards one that is person-centred rather than task-focused. An analysis of key events over the day – such as meal times or activity sessions or handovers – often reveals where changes can be made that will improve levels of well-being of the whole group of service users. At a management level within care organizations, DCM data can help in decisions around skill mix, training needs and staff development. DCM sheds light on those skills that engender well-being. It can be useful in tailoring training and staff development programmes
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around specific examples from the lived experience within an organization. An advantage of DCM is that it can be used over time to monitor change at all these levels, thus evaluating whether the changes have had an impact. DCM data can be analysed to monitor change over time at an individual resident level and at an organizational level. DCM data can be utilized to good effect in fulfilling a number of reporting requirements for commissioners and inspections.
USING DCM TO CHANGE THE CULTURE OF CARE In 2001, an international ‘think tank’ of DCM practitioners came together to review their collective experience on DCM25 . Their conclusions from practice were that DCM, used within an organizational framework that supported person-centred care, could improve levels of well-being, increase the diversity of occupation, and decrease the incidence of personal detractions. The published developmental evaluations although limited in number supports this assertion both for larger scale quality-assurance initiatives9,10 and more indepth developments in single establishments12,26 . A recent Australian cluster-randomized control trial of DCM demonstrated that DCM improved levels of agitation and that the number of falls decreased in care homes that used DCM27 . Using DCM to achieve culture change is not an easy or trivial process. It does not provide a quick fix solution. This fact needs to be engaged with by both staff and management teams prior to deciding to use DCM. DCM is unlikely to have a positive impact unless staff have the necessary knowledge and skills base to use the information it generates. Also, as DCM works through helping staff teams reflect on their practice to bring about quality improvements, mechanisms such as supervision, mentoring, governance and quality assurance groups need to be established at an organizational level for DCM to work effectively over a sustained period of time. Bringing DCM into an organization as a driver for person-centred care practice is a major undertaking. It requires clear strategic and operational planning if there is to be a maximum return on investment. Many organizations spend over a year planning and ensuring they are prepared before embarking on their first DCM evaluation. The British Standards Institute have developed a Publically Accessible Specification28 to provide health and social care organizations with comprehensive guidance to assist them in this process.
USING DCM IN RESEARCH The University of Bradford maintains a DCM bibliographic database that contains all known publications on DCM (http://www.bradford .ac.uk/acad/health/dcm). It is updated by the Bradford Dementia Group with annual bibliographic searches on Medline, Cinahl, and Psychinfo using the terms ‘DCM’ and ‘dementia care mapping’ as well as personal correspondence from practitioners and researchers. A review of the published literature on DCM8 revealed a number of papers of variable quality dating back to 1995 that have used DCM in a research context. These were categorized into the following types: 1. Cross-sectional surveys: Ten papers reported DCM results across a number of different facilities, and the results either compared or pooled. An additional three papers used DCM to investigate the relationship between participants’ characteristics and well-being and activity.
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2. Evaluations of interventions: In a further ten papers DCM was used to evaluate the impact of various interventions including a number of non-pharmacological therapeutic interventions and a double-blind, placebo-controlled, neuroleptic discontinuation study29 . 3. Practice development evaluations: Six papers investigated the ability of DCM to develop practice over time by means of repeated evaluations. 4. Multi-method evaluations: Three articles reported using DCM as part of a multi-method evaluation of a single facility or service. DCM was not designed to be a research tool. Careful consideration should be given in deciding whether DCM is fit for purpose given the specific topic under investigation. In terms of cross-sectional surveys, there are tools that may be more suited to this task that do not have the attendant time-consuming problems and specialist training associated with DCM. DCM seems to be suited to smaller scale within-subjects or group comparison intervention evaluations, given that it appears to demonstrate discrimination on a variety of interventions. In multi-method qualitative designs, DCM appears to enrich the data derived from proxy and service-user interviews and focus groups. DCM provides an opportunity to represent a reflection on what could be the viewpoint of service users who are unable to participate fully in interviews. What is clear is that BCCs do not measure real-time estimates of different types of behaviour18 . Because of the rules of coding in DCM, it will underestimate the occurrence of socially passive and withdrawn behaviour compared with data collected with continuous time sampling. Researchers interested in looking at withdrawn and passive behaviour might be better advised to use another tool. It is worthy of note, however, that despite this, three studies21,30,31 found DCM discriminated between groups on social withdrawal in their evaluations. There are a number of modifications to DCM that might prove useful when using DCM in research32 .
CONCLUSIONS DCM has a long history and it has changed over time. It has been taken up by practitioners in many countries who wish to improve the quality of care for people with dementia. It can be used on an individual client level or to improve group care. It requires specialist training to use and it takes careful planning to ensure that it is used to good effect. It has been utilized as a research tool for a variety of purposes. DCM’s advantages are that it is standardized, quality controlled, international, responsive to change, multidisciplinary and has an increasing research base. Its disadvantages are that it is resource heavy in terms of its training and administration. DCM holds a unique position in relation to quality of life in dementia care, being both an evaluative instrument and a vehicle for practice development in person-centred dementia care.
REFERENCES 1. Kitwood T, Bredin K. A new approach to the evaluation of dementia care. J Adv Health Nurs Care 1992; 1: 41–60. 2. Brooker D, Surr CA. Dementia Care Mapping: Principles and Practice. Bradford: University of Bradford, 2005.
3. Brooker D. What is person-centred care for people with dementia? Rev Clin Gerontol 2004; 13: 215–22. 4. Kitwood T. Dementia reconsidered: the person comes first . Buckingham: Open University Press, 1997. 5. Adams T. Kitwood’s approach to dementia and dementia care: a critical but appreciative review. J Adv Nurs 1996; 23: 948–53. 6. Brooker D, Surr C. Dementia Care Mapping (DCM): Initial validation of DCM 8 in UK field trials. Int J Geriatr Psychiatry 2006; 21: 1018–25. 7. Surr C, Brooker D. The effects of undertaking a DCM training course on care practice. Signpost 2002; 7: 16–18. 8. Brooker D. Dementia Care Mapping (DCM): a review of the research literature. The Gerontologist 2005; 45: 11–18. 9. Brooker D. Foster N. Banner A. Payne M, Jackson L. The efficacy of Dementia Care Mapping as an audit tool: report of a 3-year British NHS evaluation. Aging Mental Health 1998; 2: 60–70. 10. Martin GW, Younger D. Person-centred care for people with dementia: a quality audit approach. J Psychiatr Mental Health Nurs 2001; 8: 443–48. 11. Williams J, Rees J. The use of ‘dementia care mapping’ as a method of evaluating care received by patients with dementia: an initiative to improve quality of life. J Adv Nurs 1997; 25, 316–23. 12. Wylie K. Madjar I, Walton J. Dementia Care Mapping: a personcentered approach to improving the quality of care in residential settings. Geriaction 2002; 20: 5–9. 13. Brooker D. Edwards P, Benson S (eds), DCM: Experience and Insights into Practice. London: Hawker Publications, 2004. 14. Fossey J, Lee L, Ballard C. Dementia Care Mapping as a research tool for measuring quality of life in care settings: psychometric properties. Int J Geriatr Psychiatry 2002; 17; 1064–70. 15. Bredin K, Kitwood T, Wattis J. Decline in quality of life for patients with severe dementia following a ward merger. Int J Geriatr Psychiatry 1995; 10: 967–73. 16. Edelman P, Fulton BR, Kuhn D. Comparison of dementiaspecific quality of life measures in adult day centers. Home Health Care Serv Q 2004; 23: 25–42. 17. Parker J. Education and learning for the evaluation of dementia care: The perceptions of social workers in training. Educ Ageing 1999; 14: 297–314. 18. Thornton A, Hatton C, Tatham A. DCM reconsidered: Exploring the reliability and validity of the observational tool. Int J Geriatr Psychiatry 2004; 19: 718–26. 19. Surr C, Bonde-Nielsen E. Inter-rater reliability in DCM. J Dement Care, 2003; 11: 33–36. 20. Jarrott SE, Bruno K. Intergenerational activities involving persons with dementia: an observational assessment. Am J Alzheimer’s Dis Other Dement 2003; 18: 31–37. 21. Gigliotti CM, Jarrott SE, Yorgason J. Harvesting health: effects of three types of horticultural therapy activities for persons with dementia. Dementia 2004; 3: 161–70. 22. Finnamore T, Lord S. The use of Dementia Care Mapping in people with a learning disability and dementia. J Intellect Disabil 2007; 11: 157–65. 23. Woolley RJ, Young JB, Green JR, Brooker DJ. The feasibility of care mapping to improve care for physically ill older people in hospital. Age Ageing 2008; 37: 390–95. 24. Boor A, Knight C. The utility of dementia care mapping within a Huntington’s disease service as a quality outcome measure. Huntington’s Dis Assoc Newsl 2007 (December).
DIAGNOSIS AND ASSESSMENT 25. Brooker D, Rogers L (eds). DCM Think Tank Transcripts 2001 . Bradford: University of Bradford, 2001. 26. Lintern T, Woods R, Phair L. Training is not enough to change care practice. J Dement Care 2000; 8: 15–17. 27. Chenoweth L, King MT, Jeon Y et al. Caring for Aged Dementia Care Resident Study (CADRES) of person-centred care, dementia-care mapping, and usual care in dementia: a cluster-randomised trial. Lancet 2009; 18: 317–421. 28. British Standards Institute. PAS 800:2010 Use of Dementia Care Mapping for person-centred care in a care provider organization – Guide. BSI: London, 2010. 29. Ballard C, Thomas A, Fossey J et al. A 3-month, randomised, placebo-controlled, neuroleptic discontinuation study in 100 people with dementia: The Neuropsychiatric Inventory is a
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predictor of clinical outcome. J Clin Psychiatry 2004; 65: 114–19. 30. Ballard C, O’Brien JT, Reichelt K, Perry E. Aromatherapy as a safe and effective treatment for the management of agitation in severe dementia: The results of a double blind, placebo-controlled trial with Melissa. J Clin Psychiatry 2002; 63: 553–58. 31. Potkins D, Myint P, Bannister C et al. Language impairment in dementia: Impact on symptoms and care needs in residential homes. Int J Geriatr Psychiatry 2003; 18: 1002–1006. 32. Sloane P, Brooker D, Cohen L et al. Dementia Care Mapping as a research instrument. Int J Geriatr Psychiatry 2007; 22: 580–99.
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Staging Dementia Barry Reisberg1 , Imran A. Jamil1 , Sharjeel Khan1 , Isabel Monteiro1 , Carol Torossian1 , Steven Ferris1 , Marwan Sabbagh2 , Serge Gauthier3 , Stefanie Auer4 , Melanie B. Shulman1 , Alan Kluger1 , Emile Franssen1 and Jerzy Wegiel5 1 Aging
and Dementia Clinical Research Center, New York University Langone Medical Center, Center of Excellence on Brain Aging, New York, NY, USA 2 Cleo Ruberts Center, Banner-Sun Health Research Institute, Sun City, AZ, USA 3 McGill Center for Studies in Aging, Douglas Hospital, Montreal, Quebec, Canada 4 MAS Alzheimerhilfe, Bad Ischl, Austria 5 New York State Institute for Basic Research in Developmental Disabilities, Staten Island, New York, USA
INTRODUCTION AND OVERVIEW OF DEMENTIA STAGING Dementia is a progressive pathological process extending over a period of many years. Clinicians and scientists have long endeavoured to describe the nature of dementia progression. Such descriptions have generally been encompassed within two broad categories: global staging and more specific staging, sometimes referred to as axial or multi-axial staging. A comparison of the major current dementia staging systems with the most widely used mental status assessment in Alzheimer’s disease, the major cause of dementia, is shown in Figure 31.1. This Figure illustrates some of the major potential advantages of staging. These advantages include: (i) staging can identify premorbid, but potentially manifest conditions which may be associated with the evolution of subsequent dementia, such as subjective cognitive impairment, a condition which is not differentiated with mental status or psychometric tests; (ii) staging can be very useful in identifying subtle predementia states, such as mild cognitive impairment (MCI), wherein mental status assessments and psychometric tests, while frequently altered, are generally within the normal range and, consequently, are not reliable markers17 – 19 ; and (iii) staging can track the latter 50% of the potential time course of dementias such as Alzheimer’s disease (AD), when mental status assessments are virtually invariably at bottom (zero) scores20 . Furthermore, apart from their utility in portions of dementia where mental status and psychometric assessments are out of range, or insensitive, there are clear data indicating that staging procedures can more accurately and sensitively identify the course of dementia in the portion of the condition which is conventionally charted with mental status assessments. This latter evidence comes from longitudinal investigation of the course of AD9 , pharmacological treatment investigation of AD21 – 23 , and study of independent psychometric assessments of AD24 . For example, longitudinal study has demonstrated that the Functional Assessment Staging procedure (FAST)5 and the Global
Deterioration Scale (GDS)3 accounted for more than twice the variance in the course of AD over a five-year mean interval, compared to the Mini-Mental State Examination (MMSE)7,9 . When employed together, the GDS and the FAST staging procedures explained nearly three times the variance in the temporal course of AD compared to the MMSE (i.e. change in measure versus change in time), with the MMSE encompassing only 10% of temporal change variance and the GDS and FAST together encompassing 28% of the temporal change variance9 . In pharmacological studies, staging procedures have frequently demonstrated sensitivity to effects of the interventions in pivotal studies where mental status assessment has not shown a significant effect. This superiority in the demonstration of pharmacological treatment efficacy for staging procedures over mental status assessment has been seen for both classes of currently approved pharmacotherapeutic agents; that is, for N -methyl-D-aspartate (NMDA) receptor antagonist treatment decreasing glutamate-induced excitotoxicity, and for cholinesterase inhibitor treatment enhancing cholinergic brain functioning. For example, a pivotal, multicentre trial associated with worldwide approvals of memantine treatment for AD found a robust statistically significant effect of the memantine, NMDA receptor antagonist treatment with the FAST staging procedure, but no significant effect was observed with the MMSE evaluation21 . Similarly, in a pivotal study associated with worldwide approval of the cholinesterase inhibitor, rivastigmine, it was found that low dose treatment (1–4 mg/day) was associated with significant improvement on the GDS staging procedure, but not on the MMSE assessment22 . Additionally, study of predominantly institutionalized persons with more advanced AD in the latter portion of the MMSE range (i.e. with MMSE scores of 10 or below), with specially designed psychometric procedures for advanced AD patients, have clearly shown that the FAST staging procedures can robustly track progressive change in these more advanced AD patients, in conjunction with special psychometric procedures, whereas the MMSE does not sensitively change in this more severe range24 . Another potential advantage of staging procedures in comparison with mental status
Principles and Practice of Geriatric Psychiatry, 3rd edn. Edited by Mohammed T. Abou-Saleh, Cornelius Katona and Anand Kumar 2011 John Wiley & Sons, Ltd
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Subjective and clinically manifest cognitive impairment Clinically manifest cognitive impairment Normal adult
Dementia Severe dement. phase
Clinical diagnosis
CDR stagea GDS & FAST stagea
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Subjective cognitive impairment (SCI)
Mild cognitive Impairment (MCI)
0
0.5
1
2
1
3
4
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abcde a b c d e
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Approximately 15 years
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Psychometric tests
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Yearsb
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Mild Mod Mod AD AD sev AD
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0
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25 Questionable impairment
9 10.5
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Impaired
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f
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0 Uniform bottom scoresd and usual stage of death
Stage range comparisons shown between the CDR and GDS/FAST stages are based upon published functioning and self-care
descriptors. b
Numerical values represent time in years.
For GDS and FAST stage 1, the temporal values are subsequent to the onset of adult life. For GDS and FAST stage 2, the temporal value is prior to onset of mild cognitive impairment symptoms. For GDS and FAST stage 3 and above, the values are subsequent to the onset of mild cognitive impairment symptoms. In all cases, the temporal values refer to the evolution of Alzheimer’s disease pathology. All temporal estimates are based upon the GDS and FAST scales and were initially published based upon clinical observations in Reisberg, Geriatrics 1986; 41(4): 30–468. These estimates have been supported by subsequent clinical and pathological cross-sectional and longitudinal investigations (e.g. Reisberg et al., Int Psychogeriatr 1996; 8: 291–3119; Bobinski et al., Dementia 1995; 6: 205–1010; Bobinski et al., J Neuropathol Exp Neurol 1997; 56: 414–2011; Kluger et al., J Geriatr Psychiatry Neurol 1999; 12: 168–7912; Prichep et al., Neurobiol Aging, 2006; 27: 471–8113 ; Reisberg and Gauthier, Int Psychogeriatr 2008; 20: 1–1614; Wegiel et al., Acta Neuropathol 2008; 116: 391–40715; Reisberg et al., Alzheimers Dement 2010; 6(1): 11–2416). The spacing in the figure is approximately proportional to the temporal duration of the respective stages and substages, with the exception of GDS and FAST stage 1, for which the broken lines signify an abbreviated temporal duration spacing for this normal adult condition which lasts approximately 30 to 50 years. c
MMSE scores are approximate mean values from prior published studies.
d
For typical adult psychometric tests.
Figure 31.1 Typical time course of normal brain ageing; mild cognitive impairment associated with Alzheimer’s disease and the dementia of Alzheimer’s disease. AD, Alzheimer’s disease; CDR, Clinical Dementia Rating1,2 ; GDS, Global Deterioration Scale3,4 ; FAST, Functional Assessment Staging5,6 ; MMSE, Mini-Mental State Examination7 ; Mod AD, moderate Alzheimer’s disease; Mod sev AD, moderately severe Alzheimer’s disease. Copyright 2007, 2009 Barry Reisberg, MD. All rights reserved
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or psychometric assessment of AD and other dementias, is in identifying the management concomitants of severity assessments25,26 . Staging procedures have also been successfully applied postmortem to retrospectively assess the diagnoses (i.e. AD or other non-AD dementia) of a diverse assortment of dementia-related cases available for ‘brain banking’, but on which no antemortem clinical data were available27 . Similarly, postmortem retrospective staging procedures have been successful in establishing remarkably robust clinicopathological correlations in longitudinally studied AD cohorts10,11,15,20 .
GLOBAL STAGING Efforts to globally stage progressive dementia can be traced back at least to the early nineteenth century when the English psychiatrist, James Prichard, described four stages in the progression of dementia: ‘(1) impairment of recent memory, (2) loss of reason, (3) incomprehension, (4) loss of instinctive action’28,29 . More recently, the American Psychiatric Association’s30 Diagnostic and Statistical Manual of Mental Disorders, 3rd edition (DSM-III) recognized three broad stages in its definition of primary degenerative dementia30 . Subsequently, in 1982, two more detailed global descriptions of the progression of dementia were published. One of these, the Clinical Dementia Rating (CDR) scale1 , describes five broad stages from normality to severe dementia. The other, the Global Deterioration Scale (GDS)3 , identifies seven clinically recognizable stages from normality to most severe dementia of the Alzheimer type. A recently published abridged version of the GDS is shown in Table 31.131 . Complete versions of the CDR and the GDS scales can be found in the literature (e.g. for the original CDR, references1,32 and for the CDR ‘current version’, reference2 ; for the GDS, reference3 , and for the tabular format of the GDS, reference4 ). These two global staging instruments, the GDS and the CDR, are generally compatible except that the GDS is more detailed and specific and identifies two stages which the CDR staging does not. One of these stages identified by the GDS staging procedure but not by the CDR is a stage in which subjective complaints of cognitive deficit occur in the absence of clinically identifiable symptoms
(GDS stage 2). These subjective complaints are now recognized as occurring very commonly in older persons (e.g.33 – 35 ). Although this stage of subjective complaints continues to be identified only by the GDS staging system, studies have indicated that persons with these complaints are at increased risk for subsequent overt dementia (e.g.12,16,36 – 38 ). A distinct diagnostic terminology, namely, ‘subjective cognitive impairment’ (SCI), has recently been suggested for otherwise healthy older persons with these symptoms who are free of overtly manifest symptoms of mild cognitive impairment (MCI) or dementia14,39 . A recent study, which is apparently the first to systematically examine the prognosis of GDS stage 2, SCI persons, in comparison with persons with no cognitive impairment (NCI, GDS stage 1), from the perspective of the subsequent development of MCI or dementia, has indicated the true morbidity associated with this SCI condition. Over a mean seven-year follow-up, the risk of subsequent decline to MCI or dementia was 4.5-times greater in persons with SCI (GDS stage 2) than in persons who are free of these subjective complaints, after controlling for differences in age and other demographic variables, as well as follow-up time16 . Physiological differences between otherwise healthy older persons with these subjective complaints of cognitive impairment and similarly aged persons without these symptoms (i.e. between GDS stage 2 and GDS stage 1 subjects) have now been reported for brain metabolism and cortisol levels40,41 . Longitudinal studies are also presently confirming13,14 a previously estimated 15-year duration8 for this GDS stage 2 condition, identifying subjective impairment only, in the evolution of brain ageing and AD pathology. The GDS staging measure and associated assessments from the GDS staging system also identify a stage, GDS stage 3, for which the terminology mild cognitive impairment (MCI) was originally coined in 198842 . This GDS stage 3 is described, in part, as a stage in which: (i) the ‘earliest clear-cut deficits’ become manifest; (ii) ‘objective evidence of memory deficit is obtained only with an intensive interview’, and (iii) there is ‘decreased performance in demanding employment and social settings’. Many of the early observations with respect to the nature of MCI were made using this GDS stage 3 definition (see17 for a review), and the GDS 3 definition of MCI remains compatible
Table 31.1 Abridged global deterioration scale Stage 1: NCI. No subjective memory deficit (no cognitive impairment); no problems with activities of daily living. Stage 2: SCI. Subjective cognitive impairment (subjective memory and/or other cognitive complaints): observations, sometimes accompanied by complaints, of being forgetful, such as of difficulties with recall of names, and/or of misplacing objects. Stage 3: MCI. Earliest subtle deficits (mild cognitive impairment): difficulties often noted at work; may have become lost; may have misplaced a valuable object. Stage 4: Mild dementia. Clear deficits on clinical examination (moderate cognitive impairment): decreased knowledge of personal and/or current events; often difficulties with finances or shopping or meal preparation or travel. Stage 5: Moderate dementia. Can no longer survive independently in the community without some assistance (moderately severe cognitive impairment): difficulty with recall of some important personal details (e.g. address, names of one or more important schools attended); may require cueing for activities for daily living. Stage 6: Moderately severe dementia. Largely unable to verbalize recent events in their life (severe cognitive impairment): may forget name of spouse; incontinence develops as this stage progresses; requires increasing assistance with activities for daily living such as dressing and showering. Increased behavioural problems (e.g. agitation) or other personality problems are common. Stage 7: Severe dementia. Few intelligible words or no verbal abilities (very severe cognitive impairment): the ability to walk is lost as this stage evolves. Later, basic capacities such as the ability to sit up independently, to smile, and to move and/or to hold up the head independently are progressively lost. Copyright 1983, 2008, 2009 Barry Reisberg, MD. All rights reserved. 2009 abridged version. Original abridged version published in Canadian Medical Association Journal 2008; 179(12): 1281. Modified from Reisberg B, Ferris SH, de Leon MJ et al. The global deterioration scale for assessment of primary degenerative dementia. Am J Psychiatry 1982; 139: 1136– 9.
DIAGNOSIS AND ASSESSMENT with the current international consensus definition of MCI, published by Winblad et al. in 200419 . The CDR staging methodology identifies a CDR 0.5 stage originally termed ‘questionable dementia’, which is somewhat broader in scope than the MCI entity, and which encompasses some of early (mild) dementia, as well as the MCI clinical timeframe. At the other end of the pathological spectrum, the CDR does not identify any stage beyond that in which dementia patients ‘require much help with personal care’ and are ‘often incontinent’. In contrast, the GDS identifies a final seventh GDS stage in which patients are already incontinent and over the course of which language and motor capacities are progressively lost. Importantly, the CDR does not stage or substage the latter portion of the dementia of AD, representing nine or more years of potential life and continuing decline for these patients (see Figure 31.1). This absence of attention to the nature of severe dementia clinical changes in the CDR staging methodology may add to the neglect of persons with more advanced dementia and, in particular, the dementia of Alzheimer’s disease. In marked contrast with the CDR, the GDS identifies two stages (GDS stages 6 and 7), corresponding to the CDR 3 stage range. Additionally, the other elements of the GDS staging system, described below, chart this latter portion of the dementia of AD in detail. For example, the FAST scale (described below) identifies eight substages corresponding to the CDR stage 3, ‘severe dementia’ range. In addition to the range differences discussed above and differing staging numbers, the CDR scale and the GDS staging scale also have different procedures for scoring. The original CDR versions used a ‘sum of boxes’ procedure, with means of the sum of boxes in six CDR assessment categories, i.e. (1) Memory, (2) Orientation, (3) Judgement and Problem Solving, (4) Community Affairs, (5) Home and Hobbies, and (6) Personal Care. However, current scoring procedures for the CDR are much more complex and more weighted towards the memory category. The GDS staging procedure simply requires the choice of the most appropriate global stage, based upon cognition and functioning. GDS staging descriptors acknowledge common emotional concomitants of the stages; however these are not employed in the stage selection. The comparisons shown in Figure 31.1 between the CDR and the GDS/FAST staging categories and other assessment procedures are based upon the CDR functioning and self-care descriptions. In summary, with respect to range, the GDS staging and associated measures from the GDS Staging System, are much more detailed at both ends of the pathological spectrum of brain ageing and progressive dementia than the CDR staging. As discussed, the GDS staging identifies an SCI stage prior to the development of mild cognitive impairment, which the CDR staging does not refer to. Also, the GDS staging procedures are more rigorous in the definition of MCI and the separation of MCI from early dementia. In the severe end of the dementia spectrum, the GDS staging and the associated GDS Staging System, described in greater detail in the next section, are much more detailed than the CDR. Staging procedures have been shown to be valid and reliable methods for assessing the magnitude of pathology in AD and related dementing conditions. This validity and reliability is illustrated in this brief review for the GDS, the most detailed and explicit staging procedure. The validity of the GDS has been demonstrated in several ways. Cross-sectional studies have confirmed the consistency of the ordinal sequence and the optimal weighting of the hierarchically sequenced items embodied in the GDS stages in ageing and progressive Alzheimer’s disease (AD)42 – 45 . Thus, the specific impairments
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characteristic of each stage almost always follow the impairments described for the previous stage. Also, the grouping of impairment characteristics within stages appears to be optimal. For example, naturalistic study has supported the identification of staging phenomena, largely identical to the GDS stages, by independent layperson observers. In this study44 , a 30-item questionnaire derived from the GDS was completed by a relative or caregiver for each of 115 patients with varying degrees of dementia. Principal components analysis was used to combine the items into a single composite scale that more reliably represents distances between the 30 clinical manifestations along the continuum of cognitive decline. In the study it was found that ‘the scale scores for the clinical manifestations were observed to cluster into relatively discrete groups, suggesting naturally occurring stages or phases. Objective cluster analysis methods further confirmed the presence of distinct transitions along the cognitive decline continuum.’ It was concluded that the ‘utility of empirically derived scale values in staging the course of primary degenerative dementia is suggested.’ The relationship between the GDS stages and mental status assessments, other dementia assessments, scores on cognitive tests and other objective tests and in vivo assessments of brain change in ageing and progressive dementia have been studied in considerable detail3,42 . These studies have indicated significant correlations between all of these measures of dementia severity and the GDS stages. However, the strongest relationships have been observed between comprehensive dementia assessments such as the Mini-Mental State Examination (MMSE)7 and the progression of dementia on the GDS42 . The GDS also correlates well with independent physical markers of AD progression such as changes in neurological reflexes46 . Thus the construct validity of the GDS has been well substantiated. At least six separate studies have examined the reliability of the GDS47 – 52 . Reliability coefficients have ranged from 0.82 to 0.97 in these studies using disparate procedures in diverse settings. These studies have indicated that the GDS is at least as reliable as any other instruments upon which clinicians rely, such as the MMSE. In a reliability study in a nursing home setting51 , the GDS was found to be somewhat more reliable than the MMSE. Importantly, GDS staging has also been shown to be a reliable procedure when assessed using a telephone format52 . Global staging scales such as the GDS have certain important advantages in dementia assessment. First and foremost, these scales are strongly anchored to the clinical symptoms, behaviour and functional changes in progressive degenerative dementia, and particularly those of Alzheimer’s disease. Consequently, they discourage misdiagnosis. Unlike many mental status and other dementia test instruments, global stages are relatively stable over time and relatively resistant to practice effects. Equally importantly, global staging instruments are minimally influenced by educational background and socioeconomic status, whereas mental status and similar assessments are strongly influenced by such factors. Also, as previously noted, global staging, and in particular the GDS, covers the entire range of pathology in central nervous system (CNS) ageing and progressive dementia, whereas, for example, mental status assessments and most psychometric tests entirely fail to distinguish GDS stages 1 and 2 (i.e. NCI and SCI). Occasionally, patients may display GDS stage 3 symptomatology (MCI) and still score a perfect 30 on the MMSE. Uncommonly, dementia patients may display GDS stage 4 symptomatology (mild dementia), and still score a perfect 30 on the MMSE. Much more commonly, patients may display the clear-cut dementia symptomatology characteristic of GDS stage 4 and achieve
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MMSE scores which are near perfect or within the so-called ‘normal’ range. At the other end of the pathological spectrum, most patients at GDS stage 6 (moderately severe dementia) achieve only bottom scores on traditional psychometric tests. Over the entire course of the GDS 7 (severe dementia) stage, most patients attain only zero (bottom) scores on the MMSE. The GDS, however, describes a final seventh stage, over the course of which patients may survive for many years.
AXIAL AND MULTI-AXIAL STAGING The observation that the progression of dementia pathology is accompanied by progressive changes in more specifically defined processes, termed ‘axes’ has resulted in efforts to stage dementia in terms of those processes. Generally, axial staging has attempted to exploit progressive changes in cognition or functioning, although attempts have also been made to hierarchically stage progressive mood and behavioural changes, progressive motoric changes and progressive neurological changes, as well as other observable concomitants of dementia. These efforts can be traced back more than 40 years to the work of de Ajuriaguerra and associates53 – 55 : Swiss investigators who were strongly influenced by Piaget’s investigations of the stages of normal infant and childhood development. More recently, Cole and co-workers in Canada employed this approach in their Hierarchic Dementia Scale56 – 58 . A similar approach was pursued, apparently independently, by Gottfries and associates in Sweden59 . The CDR staging has a ‘sum of boxes’ approach which employs a hierarchical, multi-axial-like procedure60 , or, more recently, a modified, multi-axial-like procedure2 . Based upon the seven-stage GDS, Reisberg and associates also described axial and multi-axial concomitants of progressive dementia61,62 in a measure termed the Brief Cognitive Rating Scale (BCRS). Each of the BCRS axes has been enumerated to be optimally concordant with the corresponding GDS stages. Ultimately, the functional component of these BCRS axes resulted in the most detailed hierarchical staging of progressive dementia proposed to date, a 16-stage and substage measure of progressive functional change. This latter assessment is termed Functional Assessment Staging or FAST5 (Table 31.2). Like the BCRS axes, the FAST has been enumerated to be optimally concordant, in dementia of the Alzheimer type, with the corresponding GDS stages, discussed above. The FAST can be used as an independent staging measure of the magnitude of dementia pathology, or as part of the GDS Staging System45 . Advantages of the FAST staging procedure include the following: (i) the FAST is capable of describing the entire course of brain-ageing associated, cognition-based functional changes and subsequent dementia of the Alzheimer type, ordinally (i.e. hierarchically), in unprecedented detail; (ii) the scale can assist in differentiating dementia of the Alzheimer type from other dementia processes8,65,66 ; (iii) the scale can assist in identifying premature and potentially remediable functional changes in AD patients (e.g. premature loss of ambulation due, for example, to the side effects of medication)8,65,66 ; (iv) the scale permits the retrospective as well as prospective examination of the temporal course of AD10,11 ; and (v) the scale is the only current measure which permits the detailed staging of severe AD20,23,24,43 . A strong relationship between this FAST procedure and comprehensive cognitive assessments such as the MMSE has long been noted64,67 . However, because the MMSE and other cognitive modalities bottom out prior to the final five to eight FAST substages, complete concurrent validation and examination of the FAST had to
await the development of cognitive measures useful in most severe dementia. Such measures were developed towards the end of the twentieth century and do, in fact, evidence strong relationships with the final FAST stages24 . Subsequent work showed approximately equally strong relationships between this latter portion of the FAST and ostensibly cognition-independent neurological reflex changes46 , as well as hippocampal neuropathological changes in volume10 , cell number11 and the percentage of remaining hippocampal neurons with neurofibrillary changes11 , with the advance of AD as per the FAST stages and substages (reviewed in20 ). Also, the second layer of the entrohinal cortex is believed to be a very early site of AD pathology. In this layer, a very robust relationship, across the FAST severity spectrum from FAST stage 3 to 7f, with the decrement in neuronal numbers has recently been reported (r = 0.9)15 . The correlations between the advance of AD as measured with the FAST in the latter portion of the course of AD, generally after the MMSE bottom (zero) point, and cognitive, neurological reflex and neuropathological hippocampal measures are generally approximately 0.8–0.9. These diverse relationships are comparable to the correlation between the FAST and the MMSE in the MMSE-sensitive portion of the FAST staging assessment. Because of these properties and others, the FAST has proven to be of widespread utility. For example, in the United States, the FAST staging procedure has been utilized as the Medicare mandated ‘gold standard’ for hospice admission for more than a decade68 . Importantly, because of the sensitivity of the FAST staging procedure to the course of AD, not only over the final seventh stage when the MMSE is zero, but also over the course of FAST stage 6, when patients still score on measures such as the MMSE, the FAST measure has shown a significant effect on the course of AD in a pivotal multicentre drug trial, associated with worldwide approvals for memantine as the first medication for advanced AD, whereas the MMSE was not sensitive to change in this study21 . At the present time, the FAST has been used as an efficacy and/or severity assessment in all pivotal trials associated with United States and European Union approvals of medications for advanced AD (for a review, see23 ). Apart from the utility of the FAST staging, other elements of the multi-axial BCRS staging procedures have also proven useful in AD assessment. On the BCRS, Axis I assesses concentration; Axis II, recent memory; Axis III, remote memory; Axis IV, orientation; and Axis V, functioning. Axis V of the BCRS was developed and expanded in the process of the creation of the FAST staging procedure. All of these elements of the BCRS, including the FAST, have been utilized as part of the syncretic NYU CIBIC-Plus assessment measure69 . As part of the NYU CIBIC-Plus, these measures have been used as primary outcome measures in pivotal trials associated with regulatory body (e.g. FDA) approvals of two of the three medications currently approved and marketed for the treatment of AD in the United States (i.e. rivastigmine and memantine) (for a review, see23 ). At the other end of the brain-ageing and AD continuum, the BCRS Axes I to V have been found to add significantly to the GDS global assessment in predicting the risk of decline and the time to decline to MCI or dementia in ostensibly normal subjects with NCI or SCI (GDS stages 1 and 2)16 .
SUMMARY Behaviourally based brain-ageing and progressive dementia staging procedures can be useful and, frequently, superior to other assessment modalities in identifying potential treatments for AD and related
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Table 31.2 Functional Assessment Staging (FAST) and time course of functional loss in normal brain ageing and Alzheimer’s disease FAST stage
Clinical characteristics
Clinical diagnosis
1 2
No decrement Subjective deficit in word finding or recalling location of objects Deficits noted in demanding employment settings Requires assistance in complex tasks, e.g. handling finances, planning dinner party Requires assistance in choosing proper attire Requires assistance in dressing Requires assistance in bathing properly Requires assistance with mechanics of toileting (such as flushing, wiping) Urinary incontinence Faecal incontinence Speech ability limited to about a half-dozen words Intelligible vocabulary limited to a single word Ambulatory ability lost Ability to sit up lost Ability to smile lost Ability to hold up or move head independently lost
Normal adult Subjective cognitive impairment
15 years
29–30 29
Mild cognitive impairment
7 years
24–27
Mild AD
2 years
19–20
Moderate AD
18 months
15
Moderately severe AD
5 months 5 months 5 months
9 8 5
4 months 10 months 12 months
3 1 0
18 months
0
12 12 18 12
0 0 0
3 4 5 6a b c d e 7a b c d e f
Severe AD
Estimated duration in ADa
months months months months or longer
Mean MMSEb
Adapted from Reisberg, 19868 . Copyright 1984 by Barry Reisberg, MD. a In subjects without other complicating illnesses who survive and progress to the subsequent deterioration stage9 – 16 . b MMSE = Mini-Mental State Examination score (Folstein et al., 19757 ). Estimates based in part on published data summarized in Reisberg et al., 198963 and in Reisberg et al., 199264 . It should be noted that the educational level of the subjects in these studies is high (mean ∼15.5 years ± ∼ 3 years, of formal
education). The influence of these educational levels on the mean MMSE scores should be given consideration.
dementias70 – 72 , as well as in assessing the course and the management needs of the dementia patient, and also in the diagnosis and differential diagnosis of dementing disorders. In providing an overview of the course of dementias such as AD, from the initial to final clinical symptoms, staging is uniquely useful. Staging is also singularly useful in assessment at various specific points in the evolution of dementing processes. Very importantly, staging can uniquely relate to management needs and the general management import of dementing processes.
ACKNOWLEDGEMENT This work was supported in part by US DHHS grants AG03051 and AG08051 from the National Institute on Aging of the US National Institutes of Health; by grants 90AZ2791, 90AM2552 and 90AR2160 from the US Department of Health and Human Services Administration on Aging; by grant NCRRM01 RR00096 from the General Clinical Research Center Program and by Clinical and Translational Science Institute grant 1UL1RR029893 from the National Center for Disease Research Resources of the US National Institutes of Health; by the Zachary and Elizabeth M. Fisher Center for Alzheimer’s Research Foundation; by a grant from Mr. William Silberstein; by the Leonard Litwin Fund for Alzheimer’s Disease Research; by the Woodbourne Foundation; and by the Hagedorn Fund.
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The Clinical Dementia Rating Rawan Tarawneh, B. Joy Snider, Mary Coats and John C. Morris Washington University in St. Louis, St. Louis, MO, USA
INTRODUCTION The Clinical Dementia Rating (CDR) is an instrument used to assess the presence and severity of dementia of the Alzheimer type (DAT); it may be applicable to other dementias as well. The CDR was developed at Washington University School of Medicine in 1982 and revised in 1993 to improve the distinction between different severity levels. Determination of the CDR is based on separate semi-structured interviews with the patient and an appropriate informant, such as spouse or adult child, to provide information regarding the patient’s current level of cognitive function and daily activity in comparison with previously attained abilities.
DEVELOPMENT OF THE CDR Measuring dementia severity is useful for research as well as for clinical decision making. Accurate staging of dementia is particularly important in clinical trials, both to select appropriate participants with similar levels of disease severity and to monitor disease progression1 . The importance of a standardized approach to dementia staging in clinical trials is highlighted by the US Food and Drug Administration’s Guidelines for the Clinical Evaluation of Anti-Dementia Drugs: ‘the stage and severity of the dementia affecting each subject participating in a clinical trial must be assessed and recorded systematically in a manner that will be readily understood by other workers in the field’2 . Prior to the introduction of the CDR, most attempts at the clinical staging of dementia were based on psychometric tests and behavioural rating scales. Some early instruments included the Dementia Scale (DS) of Blessed, the Global Deterioration Scale (GDS), the 29-item Blessed Information and Memory Scale (BIMC), and the Short Blessed Test, an abbreviated 6-item version of the BIMC. The CDR is a ‘global’ scale that assesses impairment in cognitive ability, including the impact of cognitive changes on everyday functioning; it was designed to be performed independently of psychometric test results. The CDR assesses intra-individual change from the individual’s prior cognitive and functional ability. Psychometric testing typically compares individual performance to reference group norms. By comparing functional and cognitive changes to the premorbid (predementia) level of function for that individual, the CDR minimizes effects of confounding factors such as age, educa-
tional level and ethnicity (i.e. the individual serves as his or her own control). The CDR has been validated in several neuropathological studies of Alzheimer’s disease3 . It has demonstrated strong correlations with other behavioural and functional tests, as well as strong inter-rater correlations, attesting to its validity and reliability. While it may not be suitable for every situation, the CDR has become internationally recognized as a highly reliable diagnostic and severity-ranking scale for dementia, has been cited in over 1000 references (http:/apps.isiknowledge.com) and translated into 60 different languages and dialects (http://alzheimer.wustl.edu/cdr/PDFs/translation/). Although primarily developed to assess DAT, the addition of language and behaviour domains in the Uniform Data Set version of the CDR (UDS) has allowed its use in the evaluation of other causes of dementia4 . Online training in the use of the CDR is available at http://alzheimer.wustl.edu/cdr/Application/Step1.htm or by writing to the authors.
OVERVIEW OF THE CDR The CDR is performed in two components: a semi-structured interview with a collateral source that provides information on the individual’s premorbid level of function and any changes that have occurred, and an interview with the individual that includes some objective testing. It is determined by rating cognitive, behavioural and functional changes resulting from cognitive loss in each of six categories: Memory, Orientation, Judgement and problem solving, Community affairs, Home and hobbies, and Personal care (Table 32.1). Each category is scored independently on a 5-point scale of impairment (0 = no impairment, 0.5 = questionable or very mild, 1 = mild, 2 = moderate and 3 = severe impairment); one category, Personal care, does not have a 0.5 impairment level. The CDR scoring table includes descriptive ‘anchors’ that guide the rater in determining individual domain ratings based on both collateral source report and patient performance. The clinician uses his or her judgement to determine each rating, scoring each as independently as possible. With CDR training, clinicians can successfully distinguish between physical and cognitive causes of functional impairment and assign a CDR that accurately reflects dementia severity even in the presence of impaired physical performance6 . The global CDR is determined by applying a scoring algorithm (www.biosat.wustl.edu/∼adrc/cdrpgm/index.html), where global
Principles and Practice of Geriatric Psychiatry, 3rd edn. Edited by Mohammed T. Abou-Saleh, Cornelius Katona and Anand Kumar 2011 John Wiley & Sons, Ltd
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Table 32.1 The clinical dementia rating scale
Memory
None 0
Questionable 0.5
Mild 1
Moderate 2
Severe 3
No memory loss or slight
Consistent slight forgetfulness; partial recollection of events; ‘benign’ forgetfulness
Moderate memory loss: more marked for recent events; defect interferes with everyday activity
Severe memory loss, only highly learned material retrained: new material rapidly lost
Severe memory loss only fragments remain
Inconsistent forgetfulness Orientation
Fully oriented
Fully oriented but with slight difficulty with time relationships
Moderate difficulty with time relationships; oriented for place at examination; may have geographic disorientation elsewhere
Severe difficulty with time relationships; usually disoriented to time, often to place
Oriented to person only
Judgement and problem solving
Solves everyday problems and handles business and financial affairs well; judgement good in relation to past performance
Slight impairment in solving problems, similarities and differences
Moderate difficulty in handling problems, similarities and differences; social judgement usually maintained
Severely impaired in handling problems, similarities and differences; social judgement usually impaired
Unable to make judgements or solve problems
Community affairs
Independent function as usual in job, shopping, volunteer and social groups
Slight impairment in these activities
Unable to function independently at these activities though may still be engaged in some; appears normal to casual inspection
No pretence of independent function home; appears well enough to be taken to functions outside the family home
Appears too ill to be taken to functions outside the family home
Home and hobbies
Life at home, hobbies and intellectual interests well maintained
Life at home, hobbies and intellectual interests slightly impaired
Mild but definite impairment of functions at home; more difficult chores, and complicated hobbies and interests abandoned
Only simple chores preserved; very restricted interests, poorly maintained
No significant function in the home
Personal care
Fully capable of self-care
Needs prompting
Requires assistance in dressing, hygiene and keeping of personal effects
Requires much help with personal care; frequent incontinence
Score only as decline from previous usual level due to cognitive loss, not impairment due to other factors. Source: Morris, J.C. (1993) The Clinical Dementia Rating (CDR): current version and scoring rules. Neurology, 43, 2412–4.
CDR 0 = no dementia and CDR = 0.5, 1, 2 and 3 for very mild, mild, moderate and severe dementia. The CDR-sum of boxes (CDR-SB) is obtained by summing the scores in the individual categories, so CDR-SB ranges from 0 to 18 (‘best’ to ‘worst’ performance)7 . The CDR-SB offers some advantages: it does not require an algorithm to calculate and can be treated as interval data in statistical analysis whereas the global CDR represents ordinal data. More importantly, the CDR-SB offers a wider range of values
and increased precision for tracking changes across time. For example, mild DAT (global CDR 1) spans CDR-SB scores from 3.5 to 10, whereas moderate DAT (global CDR 2) spans 8–15.
CHARACTERISTICS The CDR has two important properties of a global staging measure: hierarchy and concordance8 . Hierarchy means that dementia severity
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is proportional to the CDR score (e.g. global CDR 3 is more severe than global CDR 2). The CDR captures different disease patterns and can identify subgroups of patients through concordance, another important property. In individuals with DAT, most of the six domains are expected to be reasonably concordant with the memory score (e.g. in global CDR 0.5 most domains would have scores of either 0.5 or 0 or 1). Disconcordance between different cognitive domains (e.g. a mix of 0, 2 and 3s) is suggestive of a non-Alzheimer’s cause of dementia. The CDR has demonstrated excellent ‘face validity’ in that it assesses the influence of cognitive loss on the ability to conduct everyday activities. It provides a standardized and meaningful way to describe clinically relevant changes to patients and their families8 . The CDR has demonstrated its validity in multiple longitudinal studies with neuropathological confirmation of Alzheimer’s disease; both the CDR and CDR-SB have been shown to correlate with the densities of neurofibrillary tangles and senile plaques, particularly in the neocortex3 . Since the inception and revision of the CDR, the diagnosis of dementia has evolved, with increasing interest in and recognition of milder stages of dementia. The CDR has demonstrated a high degree of sensitivity (91%) in distinguishing individuals with even the mildest stages of dementia from normal individuals in longitudinal studies with neuropathological confirmation of Alzheimer’s disease9 . When administered in a standardized fashion, the CDR has excellent reliability. Inter-rater reliability of the CDR in several single and multicentre clinical trials including both physicians and nonphysicians is 80% or greater for overall CDR, and ≥80% for almost all of the individual boxes10,11 . The stability of the CDR over time was investigated in a 30year longitudinal study of 1768 patients 63–83 years of age and with CDRs 0, 0.5 or 1 at Washington University13 . Over time, the participant sample became older, more highly educated, more ethnically diverse, more likely to be female and more likely to have non-Alzheimer’s disease dementias. There was a high turnover in the individual clinicians. Despite these changes, the psychometric test scores of individuals with similar CDR ratings did not change significantly over the 30-year period.
dementia even when the degree of impairment is very mild (CDR 0.5).
ADAPTATIONS OF THE CDR The CDR has been adapted to other clinical settings such as nursing homes and chronic care facilities (CDR-CC). A more abbreviated form of the CDR has been included into the Diagnostic and Statistical Manual for the identification of dementia. The CDR interview can take 45–60 minutes and may be impractical for some clinical and research settings. A software system for administration and automatic scoring of the CDR using a hand-held device platform was recently developed. The platform includes specific algorithms for each scoring domain and the global CDR. The platform increases ease of data collection and management and is transferable to other platforms, allowing its use in both research and clinical settings. The Palm-based CDR has excellent validity, reliability and high correlation with the traditional CDR and is accurate for distinguishing CDR 0 and 0.5, which is probably the most challenging distinction in practice14 . A brief informant questionnaire, referred to as ‘AD8’, has been developed in another attempt to avoid the time limitations of the CDR. The AD8 scores responses to eight questions. It offers a practical screening tool for the presence of dementia, with high sensitivity, specificity and face validity. However, in contrast to the CDR, it cannot be used as a staging tool for dementia15 .
POTENTIAL LIMITATIONS OF THE CDR The CDR is not without limitations, including reliance on clinical judgement and the availability of an observant collateral source, and the length of time required for administration. Although the semistructured interview format is flexible and can be adapted to different cultures and socioeconomic groups, social, cultural and educational factors may influence some domains of the scale. Therefore, additional validation studies will be needed to establish the validity and reliability of the CDR in ethnic subpopulations16 .
ACKNOWLEDGEMENTS DIAGNOSIS AND DETECTION OF EARLY STAGES OF DEMENTIA In its original form, CDR 0.5 denoted a heterogeneous group with questionable dementia. However, there is a growing body of evidence that many in the CDR 0.5 group are very similar to those with mild DAT in cognitive, behavioural, psychometric performance, longitudinal progression, as well as in neuroimaging and CSF biomarker characteristics. By relying on intra-individual cognitive decline rather than interindividual comparison of psychometric performances with arbitrary cut-points for impairment, CDR 0.5 allows the identification of individuals with cognitive impairment that may be too mild to fulfil criteria for mild cognitive impairment. Longitudinal studies have consistently demonstrated that the CDR 0.5 designation, when impairment is believed clinically to be caused by DAT, is followed by progressive cognitive and functional decline over time and by the histopathological changes of Alzheimer’s disease at autopsy even when the CDR 0.5 diagnosis is ‘pre-mild cognitive impairment’9 . CDR 0.5 is now considered to characterize ‘very mild’ rather than ‘questionable’ dementia. We attempt to diagnose the aetiology of
This chapter was supported by grants from the National Institutes of Aging (NIH/NIA P01AG003991, NIH/NIA P50AG005681).
REFERENCES 1. Perneczky R, Wagenpfeil S, Komossa K, Grimmer T, Diehl J, Kurz A. Mapping scores onto stages: mini-mental state examination and clinical dementia rating. Am J Geriatr Psychiatry 2006; 14: 139–44. 2. Leber P. Guidelines for the Clinical Evaluation of Antidementia Drugs. Rockville, MD: US Food and Drug Administration, 1990. 3. Berg L, McKeel DW, Jr., Miller JP et al. Clinicopathologic studies in cognitively healthy ageing and Alzheimer’s disease: relation of histologic markers to dementia severity, age, sex, and apolipoprotein E genotype. Arch Neurol 1998; 55: 326–35. 4. Morris JC, Weintraub S, Chui HC et al. The Uniform Data Set (UDS): clinical and cognitive variables and descriptive data from Alzheimer Disease Centers. Alzheimer Dis Assoc Disord 2006; 20: 210–16.
DIAGNOSIS AND ASSESSMENT 5. Morris JC. The Clinical Dementia Rating (CDR): current version and scoring rules. Neurology 1993; 43: 2412–14. 6. Shah KR, Carr D, Roe CM, Miller JP, Coats M, Morris JC. Impaired physical performance and the assessment of dementia of the Alzheimer type. Alzheimer Dis Assoc Disord 2004; 18: 112–19. 7. O’Bryant SE, Waring SC, Cullum CM et al. Staging dementia using Clinical Dementia Rating Scale Sum of Boxes scores: a Texas Alzheimer’s research consortium study. Arch Neurol 2008; 65: 1091–95. 8. Rockwood K, Morris JC. Global staging measures in dementia. In Gauthier S (ed), Clinical Diagnosis and Management in Alzheimer’s Disease. London: Martin Dunitz, 1996, 141–53. 9. Storandt M, Grant EA, Miller JP, Morris JC. Longitudinal course and neuropathologic outcomes in original vs revised MCI and in pre-MCI. Neurology 2006; 67: 467–73. 10. Morris JC, Ernesto C, Schafer K et al. Clinical dementia rating training and reliability in multicenter studies: the Alzheimer’s Disease Cooperative Study experience. Neurology 1997; 48: 1508–10.
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11. Burke WJ, Miller JP, Rubin EH et al. Reliability of the Washington University Clinical Dementia Rating. Arch Neurol 1988; 45: 31–32. 12. McCulla MM, Coats M, Van Fleet N, Duchek J, Grant E, Morris JC. Reliability of clinical nurse specialists in the staging of dementia. Arch Neurol 1989; 46: 1210–11. 13. Williams MM, Roe CM, Morris JC. Stability of the Clinical Dementia Rating 1979–2007. Arch Neurol 2009; 66: 773–77. 14. Galvin JE, Meuser TM, Coats MA, Bakal DA, Morris JC. The ‘portable’ CDR: translating the Clinical Dementia Rating interview into a PDA format. Alzheimer Dis Assoc Disord 2009; 23: 44–49. 15. Galvin JE, Roe CM, Powlishta KK et al. The AD8: a brief informant interview to detect dementia. Neurology 2005; 65: 559–64. 16. Morris JC, Cummings JL. Workshop reports from the third Asiapacific regional meeting of the international working group on harmonization of dementia drug guidelines. Alzheimer Dis Assoc Disord 2006; 20: 313.
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GMS-HAS-AGECAT Package and the Global Mental Health Assessment Tool (GMHAT): Epidemiology and Closing the Treatment Gap John R. M. Copeland Division of Psychiatry, University of Liverpool, UK
For epidemiological and other studies of mental illness and morbidity in older age it is important to ensure as far as possible that the differences in the levels of cases of illness found between geographical areas and between studies at different points in time are not due to methodological differences and, in particular, the way the diagnoses themselves are made. To overcome this problem, standardized interviews were introduced. The GMS-HAS-AGECAT Package consists of a series of interviews designed to be given to a person for assessing the dementias and depression, with optional sections for minor mental illness. The Geriatric Mental State (GMS) was derived originally from the Present State Examination and the Mental Status Schedule (see the GMS Resource Centre at www.liv.ac.uk/gms). Substantial modifications and additions were incorporated to make it more applicable to older populations and to increase emphasis on organic states. The Package now provides, in addition to the GMS, which is an interview with the subject, the History and Aetiology Schedule (HAS) for an informant, which allows the assessment of onset and course of illness, past history, family history and certain risk factors for dementia, depression and other mental illness. Standardization of diagnosis is achieved by the Automated Geriatric Examination for Computer Assisted Taxonomy (AGECAT) computer-assisted differential diagnosis based on an extensive decision tree method. The system aggregates the data into scores and allots each subject to levels of ‘diagnostic confidence’ on each of eight diagnostic syndrome clusters: organic, schizophrenia/paranoid, mania, depression (psychotic and neurotic type) (levels 0–5), obsessional, hypochondriacal, phobic and anxiety neurosis (levels 0–4). Level 3 and above are what would usually be recognized by psychiatrists as cases of illness. The computer then compares these levels with one another to derive a final diagnosis and flags cases where the decision has been difficult. The validity of the AGECAT diagnosis has been assessed against psychiatrists’ diagnoses on the same patients. The range of kappa values for the agreement between AGECAT and psychiatrists’ diagnoses for organic states is 0.80–0.88 and for depressive states 0.76–0.80. Outcome studies are now providing additional validation. After three years of follow-up, over 83% of AGECAT cases of organic disorder identified in the community study were either dead or still dementing. One third of
depressed cases were also depressed three years later. Postmortem studies have provided some validation of the dementia diagnosis1 . In the second stage AGECAT uses the data from the HAS to take the diagnosis to a further stage, dividing organic states into acute or chronic, and the latter into the different types of dementia using a standardized form of the Hachinski Ischaemia Score. It also identifies bereavements and flags co-existent immobility, pain, lifelong intellectual function and physical illness. The GMS can be used by trained lay workers and provides a diagnosis by AGECAT. When used in epidemiological studies it is possible to derive prevalence figures for the full range of psychiatric morbidity using a one-stage design. The measures are therefore economical as well as reliable and valid. The Package does not rely on special psychological tests as these are not applicable across cultures or socioeconomic groups or with populations of varying literacy. The interviews have also been transferred for presentation on laptop computer, which improves accuracy and communication, avoids delays and costs in inputting data, and provides rapid access to results and easy quality control of interviewing techniques. These measures have been used in a number of projects, including the Medical Research Council (UK) ALPHA study of the incidence of the dementias (Liverpool, UK) and the multicentre MRC Cognitive Function and Ageing Study of six centres in the UK, the EURODEP EC-funded Concerted Action across nine European centres, the ongoing ASIADEP studies in five Asian centres, and the 10/66 Dementia Research Group (www.alz.co.uk), a collective of dementia researchers from the developing world examining the validity of dementia diagnosis in 27 centres in Latin America, Africa, India and South Asia, China and Southeast Asia, as well as forming part of the minimum dataset required by the EURODEM (EC Concerted Action on Epidemiology and Prevention of Dementia). The GMS has been translated and used in 40 different languages. The HAS has been shortened and modified to provide for the criteria of Lewy body dementia, and other recognized dementia classifications2 . Of particular interest has been the question of how accurately the GMS Package diagnosed dementia among those persons with little or no education, an environment for which it was not initially developed. Findings now suggest that the GMS does tend to over-identify
Principles and Practice of Geriatric Psychiatry, 3rd edn. Edited by Mohammed T. Abou-Saleh, Cornelius Katona and Anand Kumar 2011 John Wiley & Sons, Ltd
DIAGNOSIS AND ASSESSMENT organic disorder in low education groups free of dementia. However, overall the GMS appears to have performed well, and with some minor modifications when used in conjunction with the Community Screening Instrument for Dementia (CSI-D) has made an important contribution to one-stage dementia diagnosis for use in the developing world. Ongoing studies have continued to address these issues3 . A recent development has been aimed at developing a clinical tool for areas of the world where there are no or very few psychiatrists or psychiatrically trained nurses. The Global Mental Health Assessment Tool (GMHAT4 ; see www.gmhat.org) has been developed in two versions. The first is for use as a diagnostic tool in primary care for the identification and treatment of mental illness in both young adult and older populations. Taking only 15 minutes on average and only requiring brief training in its use at high school educational level, it can be employed much as a blood test or an X-ray but much more cheaply and quickly. The second or full version, for secondary care where there is no psychiatrist, is designed to be given by a psychiatric nurse trained briefly in the method. The extensive computerized diagnostic algorithms based on the AGECAT system have been much extended to include mental illnesses encountered in younger age groups as well as those in older people (All-AGECAT) and more extended treatment options. Preliminary trials have begun in the UK, the Netherlands, Ireland, India and Africa. Closing the
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treatment gap particularly in low and middle income countries is now of growing concern. Achieving a reliable diagnosis and instituting treatment is the vital rate-limiting step on the road to recovery and return to work. In many parts of the world older people need to continue to work to support themselves and their families, especially in countries ravaged by HIV AIDS.
REFERENCES 1. MRC CFAS. Pathological correlates of late-onset dementia in a multicentre, community-based population in England and Wales. Lancet 2001; 357: 169–75. 2. Copeland JR, Prince M, Wilson KC et al. The Geriatric Mental State Examination in the 21st century. Int J Geriatr Psychiatry 2002; 17: 729–32. 3. Prince M, Acosta D, Chiu H, Scazufca M, Varghese M, for the 10/66 Dementia Research Group. Dementia diagnosis in developing countries: a cross-cultural validation study. Lancet 2003; 361: 909–17. 4. Sharma VK, Lepping P, Cummins AGP et al. The Global Mental Health Assessment Tool – Primary care version (GMHAT/PC) development, reliability and validity. World Psychiatry 2004; 3(2): 115–19.
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Assessing Life Skills Colin Depp, Veronica Cardenas, Ashley Cain and Thomas L. Patterson Department of Psychiatry, University of California – San Diego, USA
INTRODUCTION Particularly among older adults with mental illnesses, functional impairments play a critical role in clinical decisions, whether in determining a patient’s ability to maintain residence in the community or gauging how well interventions aid patients in fulfilling life roles. The goal of mental health interventions is to restore functioning as much as possible, ideally to the individual’s premorbid level of functioning, and so it follows that the measurement of functional abilities is of paramount clinical importance. By virtually any measure, the functional impact of psychiatric illness is immense and typically lifelong. Among people with schizophrenia, about two-thirds are unable to perform social roles and fewer than one-third are ever employed1 . According to the World Health Organization (WHO), depression is among the commonest causes of days of disability, among all diseases, in the developed world2 . Dementia due to Alzheimer’s disease, which is now the sixth-leading cause of death, is also a leading cause of nursing-home placement in older adults3 . In addition to the personal losses associated with functional impairment, disability associated with late-life mental illness imposes substantial monetary costs on society, such as wages lost by sufferers and their caregivers, the expense of services that compensate for functional deficits and other supportive costs. Historically, much of the focus in psychiatry has been on quantifying and treating the symptoms of mental illness, with relatively less methodological rigour on the conceptualization and measurement of everyday functioning and skills for daily life. However, recent years have seen a rapid increase in the sophistication of approaches to measure the capacity to perform activities of daily living and in the quantification of ‘real-world’ outcomes that patients and providers care about. In this chapter, we will review the domains of interest and approaches to assessing daily living skills in older people with psychiatric disorders, provide a model linking the factors that contribute to functional disability and review the measurement modalities and the instruments available to measure functional outcomes in geriatric psychiatric patients.
CONSIDERATIONS IN MEASURING FUNCTIONING Functional abilities encompass a number of life domains and there is no definitive subset of abilities under the umbrella of functional status nor a ‘gold standard’ defining functional independence or dependence. As a result, dozens of measures of functioning exist that cover
different life domains, with varying theoretical bases and psychometric properties. Recent initiatives, such as the Measurement and Treatment Research to Improve Cognition in Schizophrenia (MATRICS)4 (sponsored by the National Institute of Mental Health) have attempted to rectify the heterogeneity of functional measurement approaches by validating and recommending a core set of functional assessments. Other NIH initiatives, such as the Patient Reported Outcomes Measurement Information System (PROMIS)5 , are also underway to provide a standard ‘toolbox’ with which researchers and clinicians can select standardized population-normed instruments to measure functioning with self-report measures. While the process of identifying a ‘core’ set of functional measures is ongoing, several important dimensions must be considered in any approach. The conceptualization of functional impairments generally separates what an individual can do (capacity) from what an individual does do (actual performance). Functional capacity refers to the ability of an individual to perform a task under optimal conditions and that performance can be measured with the observational or performance-based approaches described in the latter portion of this chapter. Actual performance may be discrepant from functional capacity, as real-world performance is affected by motivation, opportunities and environmental barriers. In addition to the distinction between capacity and actual performance, the functional consequences of an illness can be judged in a number of ways. Functional status can be assessed relative to age-adjusted norms, premorbid ability or a criterion devised by an external entity (e.g. some government agency standard). The normative basis for assessing functioning is important when interpreting scores from instruments that are generic (e.g. the Medical Outcomes Study – Short Form) and meant to be applicable to the broad population. Alternatively, functioning measures can be disease-specific, such as those focusing on severe mental illnesses (e.g. the Independent Living Skills Survey). Although these latter measures may not provide an estimate of functioning relative to healthy older adults, the items may have a lower ‘floor’ and thus can guide rehabilitation targets in functionally impaired people. Another way in which functioning can be classified, typically in population-based studies, are preference-weighted approaches. These approaches use population data on preferences for states of health to create indices of disability adjusted life years (DALYs) or quality adjusted life years (QALYs), which can be compared across illnesses or treatments. For example, the Quality of Well-Being Scale uses a preference-weighted approach. Previous use of this instrument
Principles and Practice of Geriatric Psychiatry, 3rd edn. Edited by Mohammed T. Abou-Saleh, Cornelius Katona and Anand Kumar 2011 John Wiley & Sons, Ltd
DIAGNOSIS AND ASSESSMENT estimates that the ‘well years’ lost to schizophrenia among middleaged and older adults are slightly more than that experienced by ambulatory individuals with AIDS6 . Yet another distinction in assessing functioning involves the source of the information. Not surprisingly, ratings of functioning provided by patients, their family members and their clinicians often show inconsistencies – for example, patients with depression may overestimate their impairment, while patients with diminished insight due to dementia may believe they are fully capable when they are not. Family and clinician judgements of functioning may depend upon the degree to which they are familiar with the individual’s functioning in the community. Some indicators of functioning, such as employment status or medication adherence, may be dependent on contextual factors such as availability of social support. Furthermore, daily living skills must be assumed to fluctuate within the individual, based both on the context and on the course of the psychiatric illness and its treatment, such that any point-in-time assessment of functioning may be biased by state-level factors (e.g. mood state, fatigue). Taking all these considerations together, it is clear that attaining reliable and accurate representations of an individual’s level of functioning presents a challenge for clinicians and researchers. The best approach typically utilizes multiple measures of functioning (e.g. performance-based, subjective ratings) in different contexts (e.g. at home and in the clinic).
WHAT ARE THE SKILLS OF DAILY LIVING? There is no single definition of daily life skills, but the primary functional categories include activities of daily living, social role functioning, decision-making capacity and recovery. The activities of daily living (ADLs) were defined in the 1960s and a decade later they were differentiated from instrumental activities of daily living (IADLs). ADLs include toileting, dressing, transferring and other activities basic to maintaining residence in the community. IADLs are more cognitively complex and involve fine motor movements, including managing medications, using the telephone, arranging transportation, managing money and preparing meals. In the general population, impairment in ADLs and IADLs increases with age, although the overall prevalence of ADL impairment in older people seems to have declined over the past several decades7 . Change in ADLs often corresponds to change in disease status and not infrequently triggers placement in a care facility. Typically, ADLs and IADLs are rated by an observer or clinician, but self-perceived impairment in functional tasks is also frequently evaluated. Measures of perceived ability to complete functional tasks are embedded in subjective questionnaires (e.g. ‘Are you impaired in your ability to walk one mile?’) as well as whether a disease impacts functioning (e.g. ‘Has your mental health interfered with your social activities?’). Finally, a number of approaches to the measurement of general physical function are used to assess physical fitness in older adults (e.g. grip strength, sit to stand tests), but because these are not specifically tied to daily life skills, we will not describe them here. Interested readers are referred to an excellent review on these physical functioning instruments8 . Social functioning is another key domain in functional assessment. Actual performance can be measured in regard to an individual’s roles in the workplace, in close relationships and in leisure activities. In geriatric populations, particularly after retirement, social roles may be less culturally prescribed than among younger adults, which makes determining the extent of social impairment more challenging. Particularly in schizophrenia as opposed to mood disorders or
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dementia, social skills may be measured in standardized role-play tasks. These simulate conversations in which the participant’s performance is graded. The use of performance-based measures of social functioning is generally restricted to research. Another context of functional status that clinicians are frequently asked to evaluate in older adults with mental health problems is decision-making capacity, particularly with regard to medical or other major life decisions. The assessment of capacity to make decisions should be specific to the context. For example, it cannot be assumed that impairment in the handling of personal finances signifies impairment in the making of medical decisions, such as the refusal of treatment. Assessing decisional capacity typically includes four components: understanding, appreciation, reasoning and expressing a choice. Understanding describes the extent to which the individual comprehends what is at stake, i.e. probable outcomes, risks and benefits. Appreciation measures how well the individual can relate the decision to his or her own situation, while reasoning measures the quality of the mental process by which the individual arrives at that decision. Finally, expressing a choice concerns whether the individual is capable and/or willing to express a decision. Research in older patients with schizophrenia or bipolar disorder using standardized measures of decisional capacity has indicated that cognitive impairments are the single greatest predictor of impairment in decisional capacity, over and above psychotic or affective symptoms. However, the manner in which the information is conveyed to the patient, particularly whether it is repeated, appears to make a significant difference in whether capacity is achieved. It cannot be assumed that the presence of a psychiatric disorder translates to a lack of capacity. Finally, recent years have seen an emergence of a more patientcentred concept of functioning that is termed ‘recovery’. The precise definition of this term is debated, but a consensus panel formed by the US Substance Abuse and Mental Health Services Administration (SAMHSA) provided the following: ‘Mental Health recovery is a journey of healing and transformation enabling a person with a mental health problem to live a meaningful life in a community of his or her choice while striving to achieve his or her full potential’9 . Although recovery shares a focus with the above domains on functional outcomes, greater emphasis is placed on the patient’s sense of self-efficacy and meaning. The measurement of recovery is thus more idiographic than that of the domains just described. How the construction of recovery changes, if at all, across the lifespan of people with mental illnesses has received little research.
WHAT ARE THE INFLUENCES ON DAILY LIVING SKILLS? Many factors influence functioning and daily living skills, including illness, cultural issues, environmental contexts and age-related changes. In this section, we review the impact of these factors and provide an integrative model that combines them. Emerging evidence in a variety of psychiatric disorders suggests that cognitive impairments are the greatest contributors to diminished functional status10,11 . On average, the relative influence of cognitive impairments on functioning probably increases over the course of a long-term illness. This is in part due to declines in the acuity of psychopathological symptoms for people with early-onset mental illnesses12 and also because cognitive impairments beyond those associated with normal ageing may cross thresholds to create functional impairment. A number of studies have examined the relative
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impact of cognition on functioning in older patients with mental illness and the general conclusion is that cognitive impairments supersede psychopathologic symptoms in their associations with functional deficits of older adults with schizophrenia, bipolar disorder and depression13 . Among cognitive abilities, impairment in executive functioning, which includes planning, task switching and other higher order mental abilities, appears to be most influential on functional status. Recent research has suggested that even among older patients with depression or bipolar disorder, both cognitive impairments and functional problems appear to persist between mood episodes. However, concurrent symptoms do appear to produce disability, particularly in subjective functioning. In addition to cognitive impairments, among older patients with schizophrenia, negative symptoms appear to be more closely associated with functional impairment than are positive symptoms. In mixed-age patients with bipolar disorder, depressive symptoms appear to be more disabling on average than manic symptoms, in part because they are, on average, more frequent and intractable. Another general trend among older adults with severe mental illnesses is that earlier age of onset is associated with greater functional impairment, likely because functional problems have had a longer time to accrue and because patients have a comparatively shorter time in which to establish life roles free of illness. Medical co-morbidities and substance abuse also appear to produce added functional impairment. Another strong determinant of functional status and one frequently overlooked in assessment, is the patient’s environment. The concept of person–environment fit14 posits that functioning is a product of individual abilities and environmental supports. In this model, the physical and social environment may support or detract from autonomous function. For example, the elimination of high curbs can enable individuals in wheelchairs to function at a level similar to those who are not wheelchair-bound. By contrast, chaotic or novel environments may overwhelm cognitive resources and exacerbate functional deficits in vulnerable older people. Some recently developed interventions for schizophrenia15 and for dementia16 emphasize environmental supports to compensate for cognitive deficits and maintain functioning. Personal Factors
Demographics • Age • Income
Health Condition(s) • Physical • Psychiatric • Other
Level of Disability Cognitive • Memory • Attention • Other
Physical • Walking • Handling • Vision
Psychological • Depression • Mania • Psychosis
Figure 34.1 Model of functional capacity
Finally, sociocultural influences affect functioning in geriatric patients with psychiatric disorders. Culturally based expectations regarding functioning and mental illness can influence the kinds of daily tasks an older adult can accomplish. For example, older immigrants may have a language barrier or lack the means to acquire resources needed to improve functioning. Moreover, culturally diverse older adults may be accustomed to carrying out daily activities following a different set of steps or using different means from those of the dominant culture. For example, a person may not know how to refill medication by way of telephone as is often done in the United States. The person may also come from a culture with clearly defined gender roles that impede the learning of such tasks as cooking, cleaning or driving a vehicle. Culturally held beliefs about the elderly can also influence daily functioning. For example, family members may feel obligated to do things for ageing relatives to ease their burden, ensure their safety, or to express culturally appropriate reverence. This sense of duty may intensify when a psychiatric illness is involved.
INTEGRATING THE CONTRIBUTORS TO FUNCTIONAL DISABILITY: A MODEL A number of disablement models have been developed over the past three decades. Most recently, the WHO developed what it termed a revised working disability model. This model clarified certain constructs and operationalized functioning across three levels17 – 20 : the body; the person as a whole; and the person in social contexts. While this model is useful, it lacks specificity and fails to consider a host of other factors which may influence functional capacity, such as cognitive deficits, earlier age of onset of illness, the environment in which a person lives and co-morbidities such as substance abuse. The following conceptual model of functional capacity (see Figure 34.1), which incorporates many of the issues mentioned above, elaborates on the WHO model. Hypothetical paths between concepts are indicated by arrows. An important feature of this model is the role of mediation – i.e. causal links are implied between illness features and disability. Among older adults with
Enabling and Moderating Factors
External • Availability of support • Financial resources • Compensatory strategies Internal • Motivation • Self-efficacy • Locus of control
Functional Capacity
Functional Outcomes
Functional Capacity • Use transportation • Manage finances • Interact socially
IADLs • Ride bus to medical appointment • Pay bills • Hold conversation
DIAGNOSIS AND ASSESSMENT schizophrenia, recent evidence shows that the pathway between cognitive abilities and functioning may be mediated by functional capacity. Bowie et al.10 examined the relationships between functional capacity data, scores on the UCSD Performance-Based Skills Assessment (UPSA), case-manager ratings of real-world functioning (covering interpersonal skills, work skills and community activities), neuropsychological test scores and symptom levels, and they constructed a path model showing that neuropsychological performance predicted functional capacity, which in turn predicted all three domains of real-world functioning. Psychiatric symptoms, specifically depression, predicted interpersonal and work skills, while negative symptoms affected interpersonal skills independently of other predictors. However, while real-world adaptive life skills were predicted by neuropsychological performance, symptoms and functional capacity, neuropsychological performance contributed little to the prediction of real-world performance after accounting for functional capacity. This study illustrates how specific paths
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in our proposed model can be validated with data and the model provides a heuristic by which to organize assessment data in gauging individual functioning.
DESCRIPTIONS OF SPECIFIC MEASURES OF FUNCTIONING As described in the introduction, many measures of functioning exist with different psychometric properties, formats and content. In considering which measure to use, it is important to recognize that all have limitations in terms of completeness, ceiling and floor effects, sensitivity to change and applicability across multiple patient groups (e.g. inpatients vs. outpatients). Measures for assessing functioning fall into four broad categories: self-reports, informant reports, clinician ratings and observational measures. Below and in Table 34.1 we have selected from among the best validated of these measures and describe the instruments in detail.
Table 34.1 An overview of specific functional instruments Measure
Time to administer
Domains assessed
Type of administration
Functional capacity: household chores, communication, finance, transportation and planning recreational activities Functional capacity: finances and communication Social skills
Performance-based
Predictive of one’s ability to live independently in the community
Performance-based
Highly correlated with full UPSA
Performance-based
Excellent inter-rater reliability, good test–retest reliability; scores correlate with health-related QWB and observed performance on activities of daily living Significantly related to prescription refill records, performance-based measures of everyday functioning and self-reported quality of life Marginal to good internal consistency, stability and inter-rater reliability; good ability to predict employability Good reliability and a valid measure of psychiatric disturbance in severely mentally ill Good internal reliability and construct validity Results comparable to interviewer-administered version
UPSA
30 minutes
UPSA-Brief
10–15 minutes
SSPA
20 minutes
MMAA
15 minutes
Medication management ability
Performance-based
ILSS-SR
20–30 minutes
Functional living skills (see text for full list)
Self-report
GAF
5–15 minutes
Functional impairment secondary to mental illness
Clinician-rated
SF-36
5–10 minutes
Self-report
QWB-SA
15 minutes
Mental and physical health-related quality of life Quality adjusted life years
SAFE
MOSES
Health-related quality of life Adaptive functioning; social-interpersonal, instrumental and life skills functioning Levels of functioning in self-care, levels of organization, depressed and anxious mood, irritability and behavioural withdrawal
Self-report
Validity, relationship to real-world outcomes
Observational
Good convergent, discriminant and predictive validity
Observational
Satisfactory validity against other established measures (Zung depression, Robertson short mental status, Kingston dementia, PAMIE scales)
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SELF-REPORT Generic Measures
SF-36 The Medical Outcomes Study (MOS) 36-item short-form Health Survey (SF-36) is a self-report measure that covers eight different domains: physical functioning, role limitations due to physical health problems, bodily pain, general health perceptions, vitality, social functioning, role limitations due to emotional problems and mental health. These eight subscales are combined to produce two summary scores: the physical and the mental composite score21 . An even shorter 12-item (SF-12) scale has been developed that can be completed in one or two minutes22 .
QWB The Quality of Well-Being (QWB) is a preference-based questionnaire that measures health-related quality of life. The original version was administered by an interviewer, but a self-administered version (QWB-SA) was subsequently developed to avoid some of the difficulties associated with interviewer administration. The QWB-SA consists of five sections totalling 56 items that assess acute or chronic symptoms, self-care, mobility, physical functioning and performance of everyday activities. Participants are asked to think about the past three days and indicate if they experienced the symptom or problem on the previous day, two days ago, three days ago, or some combination thereof. The QWB-SA takes approximately 15 minutes to complete23 .
while a three is complete dependence. Slightly more sensitive than the Katz is the Barthel index, which uses 10 different categories. In addition to the six categories used in the Katz, the Barthel index divides toileting into bladder and bowel control and adds walking, stair climbing and grooming. Higher scores are assigned to those with higher levels of independent functioning, for a possible total of 100 points26 .
IADL The Instrumental Activities of Daily Living Scale (IADL) covers the more complex instrumental activities that are needed to live independently. The IADL evaluates ability to use a telephone, shop, prepare food, keep house, do laundry, use transportation, take medication and manage finances. Typically, women are scored on all eight domains, while for men, food preparation, housekeeping and laundering are sometimes excluded27 .
RIL Another example of an informant-completed measure is the Record of Independent Living (RIL). The informant rates the patient on the categories of activities, communication and behaviour. Ratings for activities range from 0 (no change when compared to previous competence) to 4 (patient no longer performs this activity) with allowances for ‘don’t know’ or ‘not applicable.’ Similarly, ratings for communication range from 0 (no difficulty) to 4 (no longer performs this function). The behaviour section consists of a checklist on which the informant indicates whether specific problem behaviours were present before the illness and whether they are currently present28 .
Disease-Specific Measures
ILSS The Independent Living Skills Survey (ILSS) tests basic functioning in patients with severe and persistent mental illness. There are two versions: informant-rated (ILSS-I) and self-report (ILSS-SR). The ILSS-I consists of 103 items that assess 12 areas of basic community living skills. The ILSS-SR has 70 items that cover 10 different domains: personal hygiene, appearance and care of clothing, care of personal possessions and living space, food preparation, care of personal health and safety, money management, transportation, leisure and recreational activities, job seeking and job maintenance. Participants are asked to indicate by a ‘yes’ or ‘no’ response whether they had performed a specific task in the past month. The ILSS-SR takes approximately 20 to 30 minutes to complete24 .
CLINICIAN-RATED GAF The Global Assessment of Functioning (GAF) describes a person’s overall psychological, social and occupational functioning. It is used as Axis V in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition and consists of 10 ‘ranges of function’ that total 10 points each, for an overall possible score of 100. A perfect score indicates superior functioning, while a score of less than 10 indicates ‘persistent danger of severely hurting self or others, or inability to maintain minimal personal hygiene, or serious suicidal act with clear expectation of death’. The GAF co-mingles functional impairment and psychiatric symptoms and so it is not a ‘pure’ measure of functioning as is the ILSS25 .
INFORMANT RATINGS
OBSERVATION
ADL
SAFE
Some patients, such as in Alzheimer’s disease, may not be able to complete a self-report measure. In such cases, an informant provides information on life skills. Typically, the informant is a spouse, an adult child, or a caregiver who spends at least two days a week in direct contact with the patient. The Katz activities of daily living (ADL) index is one of the more widely used informant-rated measures. Caregivers rate the patient’s level of dependence on others in six different areas: bathing, dressing, toileting, transferring, continence and feeding. A zero score indicates complete independence,
The Social Adaptive Functioning Evaluation (SAFE) was developed for a geriatric psychiatric inpatient population to evaluate socialinterpersonal, instrumental and life-skills functioning. This 17-item scale is scored using observation, caregiver contact and interaction with the subject. These items assess self-care, social competence and adjustment and miscellaneous skills such as impulse control and cooperativeness. Items are rated on a 5-point scale with higher scores reflecting greater impairment. This scale is useful because the patient can be rated regardless of their cooperation or responses29 .
DIAGNOSIS AND ASSESSMENT
MOSES The Multidimensional Observation Scale of Elderly Subjects (MOSES) is an observation-based measure that can be completed by nurses or staff at residential facilities. It consists of 40 items that measure five different areas of functioning related to life in a residential facility: self-care, levels of organization, depressed and anxious mood, irritability and behavioural withdrawal. There is also a briefer 24-item version30 – 32 .
PERFORMANCE-BASED MEASURES UPSA The UCSD Performance-Based Skills Assessment (UPSA) uses roleplay tasks to examine five areas of everyday functioning including household chores, communication, finance, transportation and planning recreational activities. Patients are asked to plan a trip to the beach, write a cheque, read a bus route map, complete a shopping list and call a doctor to reschedule an appointment. It typically takes about 30 minutes to administer and includes several props such as grocery items, maps and a telephone. The UPSA has shown excellent reliability as well as strong convergent validity and good criterion validity with real-world outcome measures33 . Also available is the UPSA-Brief, which includes only the communication and finances sections of the original UPSA. The UPSA-Brief and UPSA show high levels of convergence in predicting real-world functional outcomes.
MMAA The Medication Management Ability Assessment (MMAA) also uses role-playing tasks, specifically focused on assessing a patient’s ability to manage a moderately complex prescription medication regimen similar to one an older adult might typically encounter. The interviewer shows the patient four standard prescription pill bottles with mock labels and filled with differently coloured dried beans. The labels read: Parlenol: Take 2 tablets twice a day with food; BRB: Take 1 tablet 3 times per day; Cyclomeovan: Take 2 tablets three times a day on an empty stomach (i.e. at least 1 hour before or 2 hours after a meal); and Linophen: Take 2 tablets 4 times a day. The interviewer then removes the bottles and an hour later the interviewer asks the participant to ‘walk’ verbally through his or her day, handing the interviewer the appropriate type and number of pills at the appropriate times. Scores are based on the total number of correct responses for a possible total of 25 points. The number of pills over and under the prescribed amount is also scored. The MMAA has excellent test–retest reliability and good construct validity, with scores significantly correlated with two other performance-based measures of functionality34 .
SSPA The Social Skills Performance Assessment (SSPA) is designed to measure everyday social skills. This performance-based measure consists of two role-playing tasks, each lasting three minutes. In the first task, the interviewer plays a new neighbour and the participant’s goal is to initiate an acquaintance with the new neighbour in a ‘friendly and informative manner’. In the second task, the participant plays a tenant who must contact his or her landlord (played by
181
the interviewer) to discuss a leak that needs to be repaired immediately. Each scenario is scored from 1 (low) to 5 (high) on various factors including: interest/disinterest, fluency, clarity, focus, affect, grooming, social appropriateness, overall conversation, negotiation ability, submission/persistence and overall argument. The entire measure takes about 20 minutes to administer35 .
SUMMARY We have described a general approach to assessing life skills in older people with psychiatric disorders, an integrative model linking the determinants of functioning with each other and specific instruments that cover multiple modalities. The best approach to measuring functioning integrates multiple assessments modalities in different contexts and uses both subjective and objective data obtained from the patient, family or other proxy informants and direct observation. The use of instruments validated in geriatric populations, such as the ones we have described, will increase the reliability and interpretability of assessment. As the focus of psychiatric care shifts from symptoms to broader functional outcomes and recovery, expanding the evidence base for functional assessments will become all the more important.
ACKNOWLEDGEMENTS The authors would like to acknowledge the following sources of funding which supported the writing of this chapter: for Dr Depp, K-award No. MH077225; for Dr Cardenas, training grant No. T32 MH 019934-15 (Jeste, Dilip); and Dr Patterson, R01 MH078737 and the Department of Veteran Affairs.
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35
Quality of Life Measures in Old Age Juanita Hoe, Martin Orrell and Gill Livingston Department of Mental Health Sciences, University College London, UK
INTRODUCTION The maintenance of physical and cognitive functioning and the avoidance of disease are associated with well-being and quality of life (QoL) in old age, as poor health can lead to loss of control, autonomy and independence1,2 . Traditionally, outcomes of treatment have been evaluated in terms of mortality or symptoms, but a more important outcome measure may be the patient’s perspective, as symptoms may improve in one area while overall quality of life decreases because of the negative effects of treatment3 . The emergence of QoL as a fundamental measure for evaluating and monitoring health outcomes in old age is attributed to the ethical and economic concerns associated with the ageing population and the concomitant increase in chronic illness and disability. Birren and Dieckmann4 identify three main areas of concern associated with this increase: (i) the impact on health service resources and the potential financial burden anticipated; (ii) the intrusive use of medical technologies; and (iii) the QoL for people in institutions. In chronic illness, people can suffer from both the disability and the treatment5 . Moreover, treatment can often result in limited gains in terms of survival, or absence of cure, which changes the balance as to acceptable side effects. Aggressive interventions may have therapeutic benefits that are overshadowed by the negative effects, thus leading to reduced QoL overall. Any detrimental impact on QoL needs to be weighed against the advantages offered through treatment6 . It is the individual’s perception that predicts whether they seek help, accept treatment or regard themselves to be well and recovered, and therefore, should be part of any outcome measures7 . Thus, subjective health measures can be used to help provide a fuller picture of the individual’s health state.
THE MEANING OF QoL The term quality of life is used frequently in everyday life, with most people assuming they know what it means without considering how to define or measure it. In terms of health, QoL has become a popular, broadly used expression that is frequently taken for granted without the meaning being clear. There is debate about the true definition and meaning of QoL, particularly whether ratings should be objective or subjective, what criteria should be used and what is actually being measured, ‘the quality of an individual’s life, state of life, or the meaning of life in general’8 . QoL is argued to be less related to basic needs than to individual expectations and experiences of life, which include individual perceptions of well-being,
happiness, goodness and satisfaction with various aspects of their lives and environment9 – 11 . What is apparent is that QoL is a multidimensional concept ‘just as is life itself’12 . A wide range of domains is suggested for inclusion as QoL indicators, including physical and mental health, intellectual and emotional function, social and role function, activities of daily living, economic aspects, and job and life satisfaction13 – 15 . The expression QoL may also overlap with the terms ‘health status’ and ‘functional status’, and have been considered interchangeable16 . Perceptions of well-being may, however, be influenced by psychological factors unrelated to health or function17 .
DEFINITIONS AND CONCEPTUALIZATIONS OF QoL There are several meanings of the term QoL, which remains a vague, elusive concept for which there is no single widely accepted definition. The definitions provided are broad and varied; indeed, there may be as many QoL definitions as there are people18 . QoL is viewed as ‘a concept which incorporates all aspects of an individual’s existence’19 and as ‘an abstraction which integrates and summarizes all those features of our lives that we find more or less desirable and satisfying’20 . The inclusion of the terms life satisfaction, morale and happiness are debated but may be considered to be transient states which should be distinguished from QoL as they differ in their degree of subjectivity21 . Alternatively, life satisfaction, self-esteem and physical health are argued to be key dimensions of QoL22 . Lawton23 defines QoL as ‘the multidimensional evaluation, by both intrapersonal and social-normative criteria, of the person–environment system of an individual in time past, current and anticipated’ and hypothesizes four dimensions of QoL: behavioural competence, perceived QoL, objective environment, and psychological well-being. Each sector is intrinsic and considered core to the concept of QoL and also interlinked. Fundamentally, QoL is perceived as being continuous and dynamic in nature and may be evaluated negatively or positively depending on the individual’s own internal perceptions and response to their environment.
HEALTH-RELATED QoL Within the context of health, QoL is defined as a reflection of patients’ perception and response to their health status and to other non-medical aspects that have an impact on patients’ lives, and within health-related quality of life (HRQoL) this includes physical,
Principles and Practice of Geriatric Psychiatry, 3rd edn. Edited by Mohammed T. Abou-Saleh, Cornelius Katona and Anand Kumar 2011 John Wiley & Sons, Ltd
PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRY
Daily roles Personal relations Positive affect Negative affect Behaviour Symptoms Disability
High Objective health status
High
Physical
Psychological
Functioning
th
Quality of life Q (X,Y )
ns
ai
m
do
Lerner31 argues that ‘health is more than just a biomedical phenomenon; it involves a social human-being functioning in a social environment with social roles they need to fulfil’. The use of QoL as an outcome measure focuses the impact of the patient’s condition and treatment on their emotional and physical functioning and lifestyle3 . Hence, health-related QoL has become important in measuring the impact of chronic disease16 . This is of particular significance as patients with the same clinical symptoms often differ in their evaluation of what the illness means to their life. The term ‘disability paradox’ is used to describe how patients with significant health and functional problems frequently have high QoL scores despite their health status32 . QoL measures can be used to evaluate human and financial costs-benefits of interventions and care provided through assessing change in physical, functional, mental and social health33 . Calman34 suggests that people perceive QoL in relationship to their past experiences, current lifestyle, hopes and ambitions for the future. QoL measures the gap between the individual’s present experience and their expectations for the future. QoL can therefore be improved by narrowing this gap, either by improving experience or lowering expectations34 . Importantly, the model recognizes the highly individual nature of QoL and the influence of culture and past experience35 . Carr et al.36 further propose a model of the relation between expectations and experience and identify three areas of difficulty in measuring QoL: people have different expectations; people are at different stages of their illness when QoL is measured; and expectations may change over time. By providing health education, information and increasing awareness of risks, patients are helped to adapt to their disability through changing their health expectations. The impact of the disability on their QoL may thus be reduced36 .
Work
al
MEASURING QoL IN HEALTH
Measurement scales Z
He
psychological and social perspectives24,25 . This definition is in keeping with that given by the World Health Organization Quality of Life Group (WHOQOL), as ‘the individuals’ perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns’26 . This broad description encompasses the complex nature of the person’s physical, psychological and social well-being in relation to their environment. The recognition of cultural factors is particularly important when considering the QoL of the ageing population and especially those people with dementia. Memory impairment is not regarded as so important in all cultures27 . Similarly, functional disability may seem less important in cultural contexts where independence and autonomy in activities of daily living are a less central part of the older person’s role28 . Older people are frequently marginalized as society holds a negative view of their QoL, and health and social research tends to focus on decline and disability29 . There are, however, both positive and negative elements that impact on an older person’s QoL, and Hughes30 identifies the key domains that should be evaluated when measuring older people’s QoL. These include physical environment, social environment, socioeconomic, cultural and health status, personality and personal autonomy factors.
Social
184
Low Low
Y
Low Subjective perceptions X
High
Figure 35.1 Conceptual scheme of the domains and variables involved in a QoL assessment Source: Reproduced with permission from Testa & Simonson (1996), New England Journal of Medicine, 334: 834–840. Copyright 1996 Massachusetts Medical Society. All rights reserved.
by interventions. Objective factors are primarily needs based and incorporate basic needs that determine people’s well-being in society, such as environment and material resources, including levels of income, crime, pollution, transport, housing type, access to amenities and employment2,37 . Subjective factors include life satisfaction and psychological well-being, morale, individual fulfilment, happiness and self-esteem, and are expressed in terms of satisfaction, values and perceptions of individual life circumstances1 . While health status is defined through the objective components, QoL is determined through subjective perception and expectations (Figure 35.1)33 . The subjective perceptions thus translate that objective assessment into the actual QoL experienced.33 Nevertheless, Bowling3 cautions that subjective measures are not designed to be used as substitutes for traditional measures of clinical endpoints but to complement existing measures and provide a fuller picture of health state. Variation among QoL scales is often due to the different emphasis placed on objective and subjective dimensions, which domains are covered and the question format rather than differences in how QoL is defined33 . The overall satisfaction an individual has with life is argued to be the most important domain of QoL2,38 . This means the importance of the individual’s personal sense of satisfaction with various areas of life is recognized; these include physical comfort, emotional well-being and interpersonal connections38 .
SUBJECTIVE AND OBJECTIVE DIMENSIONS OF QoL
VALIDITY AND RELIABILITY
Testa and Simonson33 recommend that measures of QoL should cover the objective and subjective components important to the relevant patient group that may be affected positively or negatively
QoL scales should be able to demonstrate validity but this is complicated as there is no measure of criterion validity: no scale can provide a full picture of people’s life quality or be relevant to all
DIAGNOSIS AND ASSESSMENT individuals33,39,40 . Content validity includes evaluation in terms of the applicability of the questionnaire and its comprehensiveness, as well as its clarity, simplicity and likelihood of bias41 . Scales should also have predictive validity, sensitivity and be responsive to change in QoL, particularly for clinically important changes3,33,42,43 . This ensures the areas relevant to the patient’s QoL are measured and that scales are responsive to the different stages of the disease and interventions or treatment given. Orley et al.44 argue that QoL is influenced by a broad range of facets and is therefore unlikely to alter markedly from day to day. Fallowfield45 recommends that QoL measures should discriminate between patient groups and identify those patients experiencing good QoL and those who are not. In addition, QoL measures used in clinical practice must be appropriate and acceptable for their intended use and the results meaningful and amenable to clinical interpretation43 .
GENERIC VERSUS DISEASE-SPECIFIC MEASURES OF QoL Generic as opposed to disease-specific instruments offer broader measures of health status and are useful for making comparisons with other conditions, while disease-specific instruments are used for assessing disease-related attributes when greater sensitivity to specific aspects of the clinical condition is required3,33 . Generic measures include single indicators, health profiles and utility measures. Health profiles attempt to measure all aspects of health-related QoL potentially affected by a condition or its treatment. Thus generic instruments tend to be lengthy to ensure sensitivity and adequate psychometric properties3 . They can be applied irrespective of the underlying condition but may be unresponsive to changes in specific conditions. Disease-specific instruments aim to have greater discrimination between severity levels of a particular disease and thus have increased sensitivity to clinical outcomes44 . They are more concise and should be able to reflect clinically significant change in health status or disease severity. Therefore in order to detect significant clinical changes, generic measures may need to be supplemented with disease-specific measures16 , particularly for evaluating therapeutic interventions within clinical trials33 . The use of disease-specific measures may, however, be limited as their narrow focus may not assess the impact of disease or interventions upon wider aspects of life, which could disadvantage arguments for additional resources24,46 . Essentially the use of both generic and disease-specific measures is recommended to ensure assessment of both disease-specific and wider aspects of life and to detect positive or negative impacts of interventions3,16,24 .
METHODS OF QoL MEASUREMENT Self-Assessment Scales The use of visual analogue scales is a common method for measuring subjective experiences such as QoL47 . They are, however, time consuming to complete and may not be relevant to the experience being considered45 . Self-reports are obtained using standardized measures that have response formats with closed questions in a categorical dichotomous format (e.g. yes/no) or sequences of categorized responses (e.g. strongly agree, agree, disagree, strongly disagree). Standardized measures have fixed questions and a range of answers; Carr and Higginson32 caution that these may not measure patients’ QoL unless scores are weighted for the individual patient.
185
Individual weightings are important for obtaining a true assessment of QoL and being responsive to change. Scores may be calculated for each domain separately or combined to provide a composite or index score of overall life satisfaction. The disadvantage of scales that are calculated to produce an overall score is that the total may result from several combinations of responses, thus leading to a loss of information about the individual components of the scale48 . Muldoon et al.17 and Lawton49 both argue that the use of a composite score fails to recognize QoL measures as being multidimensional and that it is illogical to aggregate scores that combine appraisals of objective measures of behaviour, function and subjective wellbeing; and there is a need to evaluate individual domains separately within research and clinical practice12,30,49 . Alternatively, Gill and Feinstein25 advocate the use of a global rating through aggregating the scores of individual QoL domains as this explains QoL more comprehensively, and they encourage more explicit criteria or weighting of the different components that construct QoL. Furthermore global ratings have been considered more acceptable for use in clinical trials as change in QoL could be more easily distinguished.
Direct Observation Where self-ratings of QoL are difficult to elicit, such as in dementia, observational ratings may be of more benefit50 – 52 . Observational methods are undertaken either through direct observation of the person with dementia, which records the frequency at which certain behaviours present, or by applying attribute ratings of observed affect states over time. Direct observation is time consuming and costly but, it has been argued, provides the most objective method of rating QoL in dementia as the subjective component is removed49,53 . Observation requires a degree of interpretation by the rater and training to reduce any influence on the behaviour observed. In addition, multiple observations of the same individual are needed to achieve a consistent result and cannot be limited to the ‘working day’ of the observer54 . Observational tools have, however, been devised that can be used to reliably measure health-related QoL and well-being in people with dementia55,56 , with Dementia Care Mapping56 being increasingly used to assess the well-being of people with dementia in care settings. Well-being scores were found to be closely associated with QoL57 .
Proxy Ratings Proxy ratings involve a judgement of the person’s QoL being made by another person to whom they are known and may be provided by a paid or family caregiver. Proxy reports may be the only source of information available, particularly for those people with the most severe levels of cognitive impairment58 . Proxy ratings have been shown to be a reliable and valid indicator of patient QoL59,60 . Nevertheless, proxies impose their own judgement, and in dementia these are thought to be influenced by feelings of caregiver burden and depression as well as by how the person with dementia is feeling59,61 . Moreover, QoL is consistently rated lower by caregivers than by patients with mild to moderate dementia62 – 66 . While proxy ratings may be considered necessary where cognitive impairment exists, the inclusion of the individual’s own rating of QoL is the preferred method for assessment, as QoL ultimately reflects the experience of the person with the disease67,68 .
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PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRY Health and Clinical Excellence (NICE) now uses cost-effectiveness in consideration of all interventions in the UK69 .
Utility Assessments (Cost-Effectiveness) Utility measures of QoL originate from economic and decision theory and are devised to reflect the health status and value of that health status to a patient16 , to assess cost-effectiveness in health care. When applying utility measures, values are placed on different health states, and the preference of a particular health outcome is determined through calculating a single summary score3 . A common utility measure is quality adjusted life years (QALY), which are used as indicators of health gain for health service resource allocation. QALYs integrate two concepts, life expectancy and life quality, that offer a mathematical outcome for rationing the allocation of health service resources8 . Although offering a utilitarian argument for determining the greatest health gain for the greatest number, QALYs are criticized as being ageist and for focusing on cure rather than care and their use marginalizes the most disabled, elderly and chronically ill48 . Older people have a shorter life expectancy in comparison to younger people. A further criticism of using QALYs is that the ‘disability paradox’, where QoL scores do not appear commensurate with the patient’s health status, prevents direct comparisons of different patient groups for allocating resources43 . There are, however, other measures of cost-effectiveness that consider the cost per unit of health gain and do not involve years. Cost-utility ratios are being calculated in some trials in dementia using utility scores computed from the EQ-5D and societal weights. The National Institute for
MEASURING QoL IN OLDER AGE Early studies identify retirement, bereavement, loneliness and isolation as important influences on older people’s lives70 , whereas, more recent studies found that older people define good QoL as family, social contacts, health, mobility/ability, material circumstances, activities, happiness, youthfulness and living environment71 . Hyde et al.72 argue that the improved health and financial status of older people means the lives of older people have changed over recent decades, with increased healthy life expectancy and access to personal incomes, such as private pensions, share dividends and rent. The QoL of people entering old age who are younger, healthier and wealthier will differ from those much older people who are more likely to experience chronic and degenerative ill health or require palliative care. Not all older people can be assumed to suffer poor QoL and while health status is an essential component of QoL, it cannot be used as a proxy for QoL in older age72 . Individual perceptions are therefore essential in assessing health-related QoL in people of all age groups. Magaziner73 reported that a fifth of older adults living in the community and half of those living in institutions are reluctant or unable to be interviewed. In contrast, Livingston et al.74 administered the Index of Health-Related Quality of Life (IHQL)75
Table 35.1 Generic quality of life instruments for use with older people QoL measure
Target population
Respondent
EQ-5D EuroQol Group96
General
Self-report
SF-12 Ware et al.78
General
Self-report
12–36
HSQ – 12 item Radosevich and Pruitt77
General
Self-report
12–39
Early old age
Self-report
19
CASP-19 Hyde et al.72
Item no. 5
Domains
Single score
Time taken
Mobility Self-care Usual activities Pain/discomfort Anxiety/depression Physical functioning Role – physical Bodily pain General health Vitality Social functioning Role – emotional Mental health Health transition Physical functioning Role – physical Bodily pain Health perception Energy/fatigue Social functioning Role – mental Mental health Control Autonomy Self-realization Pleasure
Yes
5 mins
Yes
10 mins
Yes
10 mins
No
Not specified
DIAGNOSIS AND ASSESSMENT
187
Table 35.2 Dementia-specific quality of life instruments QoL measure
Target population
Respondent
Item. no.
Domains
Single score
Time taken
ADRQL Rabins et al.88
Mild/moderate and severe dementia
Caregiver – proxy Formal and informal
47
Yes
Not specified
DQOL Brod et al.51
Mild/moderate dementia MMSE ≥ 12
Self-report
29
No
15–20 mins
QOL-AD Logsdon et al.61
Mild/moderate dementia Severe dementia MMSE ≥ 3
Self-report+ Caregiver – proxy
13
Yes
10 mins
C-BS Ready et al.100
MCI Mild/moderate dementia MMSE ≥ 9
Self-report Caregiver – proxy
19
Yes
15 mins
DEMQOL Smith et al.99
Mild/moderate dementia MMSE ≥ 10
Self-report
28
Social interaction Awareness of self Feeling and mood Enjoyment of activities Response to surroundings Self-esteem Positive affect Negative affect Feeling of belonging Sense of aesthetics Physical health Mental health Personal relationships Finances Overall life quality Negative affectivity Positive affectivity Self-esteem Physical complaints Satisfactions Health Well-being Cognitive functioning Social relationships Self-concept
Yes
Not specified
to a community sample of 782 older people aged 65 years and older. Their study found that three quarters of the respondents were able to complete the IHQL and the other measures used; interestingly, this included those people with dementia. Those experiencing somatic symptoms or subjective memory impairment were less likely to complete the questionnaires. They found that the scale was not valid in older people. Pettit et al.76 administered the 12-item Health Status Questionnaire (HSQ-12)77 or the 12-item Short Form Health Survey (SF-12)78 to a community sample of 1 085 older people over 65 years of age. They found that both Health-Related QoL measures were acceptable and valid for use within this population. Completion rates were lower in those people with dementia and the SF-12 was found not to distinguish between people with and without dementia. It is clear, therefore, that most older people and those experiencing dementia are able to complete instruments assessing their own QoL.
MEASURING QoL IN MENTAL ILLNESS Orley et al.44 discuss the use of QoL measures in psychiatric patients and consider how QoL ratings may be affected by the impact of the disorder through disturbed affect or thinking and through institutionalization. While psychiatric symptoms such as depression may affect a person’s QoL, they do not distort it or make their perceptions invalid. In addition, while institutionalization may mean psychiatric patients perceive a good QoL due to lowered expectations, their assessments are still valid. Proxy ratings for patients with cognitive
impairment may be useful for planning and evaluating care, but they should not be taken as a measure of perceived QoL44 .
MEASURING QoL IN DEMENTIA The nature of dementia, which affects cognition and communication, means assessing QoL in dementia offers a unique challenge. The progression of dementia is non-linear; dementia has multiple causes and outcomes and is a complex disorder when compared with other health states46 . Difficulties are routinely assumed in people with dementia providing subjective assessments of their QoL or care, owing to limitations with comprehension and reliability79 . Providing an answer does not mean that the question is necessarily understood, and QoL may also be perceived differently as the disease progresses80 . However, it is logical to assume that people with dementia will have likes and dislikes55 . Even in the most severe dementia it is possible to display preferences and aversions through emotional expression. Lawton49 reasons that although subjective measures demand a degree of cognitive skill, people with dementia can provide reliable assessments of their mood and QoL. The patient’s subjective ratings of QoL are suggested as the gold standard for measuring QoL. Several studies have now shown that QoL can be reliably measured in people with mild, moderate and severe dementia using self-rating QoL scales51,61,81,82 . However, there are differences in QoL ratings as given by caregiver proxies and those given by the person with dementia62,83 – 86 . Clinicians should be aware that proxy ratings do
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PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRY
not necessarily replicate the QoL views of the person with dementia, and should not be substituted for self-ratings. Few studies have employed QoL as an outcome measure for interventions in dementia and at present the evidence is not consistent, possibly due to the variety of measures used. Studies have indicated both an increase and a decrease in QoL as dementia advances65,87,88 . Some studies that have identified cognition and dementia severity as a predictor of QoL in dementia59,89 were based on caregiver proxy ratings of the person, although more recent studies found caregiver proxy ratings of QoL were strongly associated with depression, disability, and neuropsychiatric symptoms of the person with dementia64,83,84,90,91 . Depressive symptoms have most consistently been identified as a predictor of lower QoL in dementia59,62 – 64,66,81 – 84 . A review of recent studies of QoL in dementia found that depression was most strongly associated with lower QoL in dementia, but found no consistent association between lower QoL and sociodemographic factors or a decline in cognition and functional ability92 .
Best imaginable health state 100
To help people say how good or bad a health state is, we have drawn a scale (rather like a thermometer) on which the best state you can imagine is marked 100 and the worst state you can imagine is marked 0. We would like you to indicate on this scale how good or bad your own health is today, in your opinion. Please do this by drawing a line from the box below to whichever point on the scale indicates how good or bad your health state is today.
Your own health state today
9
0
8
0
7
0
6
0
5
0
4
0
3
0
2
0
1
0
Health Questionnaire English version for the UK (validated for Ireland)
0 Worst imaginable health state
By placing a tick in one box in each group below, please indicate which statements best describe your own health state today.
Figure 35.2 (continued )
Mobility I have no problems in walking about I have some problems in walking about I am confined to bed Self-Care I have no problems with self-care I have some problems washing or dressing myself I am unable to wash or dress myself Usual Activities (e.g. work, study, housework, family or leisure activities) I have no problems with performing my usual activities I have some problems with performing my usual activities I am unable to perform my usual activities Pain/Discomfort I have no pain or discomfort I have moderate pain or discomfort I have extreme pain or discomfort Anxiety/Depression I am not anxious or depressed I am moderately anxious or depressed I am extremely anxious or depressed
Figure 35.2 EuroQol (EQ-5D) UK English version Source: Reproduced from the EQ-5D User Guide, Version 1, November 2007 by permission of the EuroQol Foundation
CHOOSING A QoL MEASURE There are a broad range of QoL scales that may be used for people with psychiatric disorder3,93 and for older people42,94 . The evidence for the validity, reliability and acceptability of generic QoL scales with older people is mixed, although their use is encouraged within research and clinical practice to promote evidence-based health care1,42,74,94,95 . Table 35.1 gives some examples of generic scales72,77,78,96 that have been used in studies involving older people with mental health needs76,97,98 . Haywood et al.’s42,94 review of QoL measures in old age found the SF-36 showed the best reliability and recommended its use where a comprehensive assessment of health is required in older people. Alternatively, the EQ-5D96 (Figure 35.2) is recommended where a briefer assessment is needed and significant changes in health are anticipated42,94 . Table 35.2 gives examples of disease-specific QoL scales in dementia51,61,88,99,100 . Each of the disease-specific QoL scales has been included in previous literature reviews examining the validity and reliability of QoL scales in dementia and their use is supported68,80,101 – 105 . The QOL-AD61 (Figure 35.3) is the preferred measure of choice, as it is brief and has demonstrated sensitivity to psychosocial interventions101 . However, none of the reviews conclusively identifies a QoL scale for use with people with dementia, and Sch¨olzel-Dorenbos et al.102 state that no QoL scale can be used across all stages of dementia.
DIAGNOSIS AND ASSESSMENT ID Number
Assessment Number
189
Interview Date
Instructions: Interviewer administer according to standard instructions. Circle your responses. 1. Physical health
Poor
Fair
Good Excellent
2. Energy
Poor
Fair
Good Excellent
3. Mood
Poor
Fair
Good Excellent
4. Living situation
Poor
Fair
Good Excellent
5. Memory
Poor
Fair
Good Excellent
6. Family
Poor
Fair
Good Excellent
7. Marriage
Poor
Fair
Good Excellent
8. Friends
Poor
Fair
Good Excellent
9. Self as a whole
Poor
Fair
Good Excellent
10. Ability to do chores around the house
Poor
Fair
Good Excellent
11. Ability to do things for fun
Poor
Fair
Good Excellent
12. Money
Poor
Fair
Good Excellent
13. Life as a whole
Poor
Fair
Good Excellent
Total Comments:
Reproduced with permission from © 1996 R.G. Logsdon. Department of Psychosocial and Community Health, Box 357263 University of Washington, Seattle,WA 98195-7263.
[email protected]
Figure 35.3 Quality of life in Alzheimer’s disease (QOL-AD) (participant version) Source: Reproduced from Logsdon et al . (2002), Psychosom. Med. Appendix 1, with permission Overall, QoL measures should be brief, easy to use, valid and reliable, sensitive to change and useful for both clinical and research settings. In dementia these should where possible include both patient and proxy ratings. It is also possible to generate QALYs from the scores of some QoL scales such as the SF-12, EQ-5D and DEMQOL, to provide an economic evaluation.
CONCLUSION Within health, HRQoL provides a global measure of well-being in patients and is an appropriate outcome measure for the assessment of disease impact and interventions provided to older people. Moreover, in chronic and disabling disorders where symptomatic and functional recovery is unrealistic, improving quality of life is a particularly worthwhile outcome. QoL is now an established outcome measure for older people and should be routinely included within studies evaluating the effectiveness of care and treatment. Further evidence is needed to show how interventions influence QoL provided to older people with mental health needs. The research undertaken in recent years has established the validity and reliability of a number of QoL measures for use with older people, particularly within dementia. Where possible the individual’s perceptions should be sought in preference to the views of others, and this may offer a challenge to health professionals working with older people experiencing increasing physical and mental frailty.
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95. Parker SG, Peet SM, Jagger C, Farhan M, Castleden CM. Measuring health status in older patients. The SF-36 in practice. Age Ageing 1998; 27: 13–18. 96. EUROQOL Group. A new facility for the measurement of health related quality of life. Health Policy 1990; 16: 199–208. 97. Wolfs CAG, Dirksen CD, Kessels A et al. Performance of the EQ-5D and the EQ-5D+C in elderly patients with cognitive impairments. Health Qual Life Outcomes 2007; 5: 33. 98. Coucill W, Bryan S, Bentham P, Buckley A, Laight A. EQ5D in patients with dementia: an investigation of inter-rater agreement. Med Care 2001; 39(8): 760–71. 99. Smith SC, Lamping DL, Banerjee S et al. Measurement of health-related quality of life for people with dementia: development of a new instrument (DEMQOL) and an evaluation of current methodology. HTA 2005; 9(10): 1–112. 100. Ready RE, Ott BR, Grace J, Fernandez I. The Cornell-Brown scale for quality of life in dementia. Alzheimer Dis Assoc Disord 2002; 16(2): 109–15. 101. Moniz-Cook E, Vernooij-Dassen M, Woods R et al., for the Interdem group. European consensus on outcome measures for psychosocial intervention research in dementia care. Aging Ment Health 2008; 12(1): 14–29. 102. Sch¨olzel-Dorenbos CJM, Ettema TP, Bos J et al. Evaluating the outcome of interventions on quality of life in dementia: selection of the appropriate scale. Int J Geriatr Psychiatry 2007; 22: 511–19. 103. Ready RE, Ott BR. Quality of life measures for dementia. Health Qual Life Outcomes 2003; 1(11). At www.hqlo.com /content/1/1/11, accessed 23 Jan 2010. 104. Salek SS, Walker MD, Bayer AJ. A review of quality of life in Alzheimer’s disease. Part 2: Issues in assessing drug effects. Pharmacoeconomics 1998; 14(6): 613–27. 105. Howard K, Rockwood K. Quality of life in Alzheimer’s disease Dementia 1995; 6: 113–16.
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Part D
Degenerative and Related Disorders
.
36
Delirium Barbara Kamholz Department of Psychiatry, Duke University, USA
INTRODUCTION Delirium is prevalent, dangerous and costly. It is caused by medical or surgical problems and medication burdens that are beyond the physiological tolerance of the patient. Delirium costs between $38 and $152 bn per year1 . In ICUs, episodes of delirium average 39% higher ICU costs and 31% higher hospital costs2 . Long considered a reversible epiphenomenon of hospital care, delirium is an independent risk factor for death and dementia3 and it contributes heavily to lengths of stay, in-hospital complications, and new institutionalization. Deliriums that are more severe or persistent have even more dire outcomes2 : 22–76% of hospitalized inpatients with delirium die4 . Delirium occurs in 15–60% of nursing home patients, 14–56% of inpatients and up to 60–80% of ICU patients5 . Yet delirium can be prevented or mitigated in health care settings that understand it, diagnose it and implement interdisciplinary programmes across the health care spectrum to address it, and there is considerable economic potential in doing so. Progress in the field has been seriously hampered by difficulties with diagnosis; up to 95% of cases are missed6 .
PRESENTATIONS, PHENOMENOLOGY AND IDENTIFICATION OF DELIRIUM Delirium is misdiagnosed in all settings, including emergency rooms, hospitals, and long term and palliative care settings. The clinical presentation of delirium remains a ‘black box’; as of this time we have no explanations for the variations in behavioural, affective, sensory and motor signs of delirium. These signs can change within seconds or hours, and most likely reflect the complex underlying pathophysiologies. The DSM IV-TR diagnostic criteria are shown in Table 36.17 . Many rating scales have been developed to assist with the diagnosis, the most widely used including the CAM8 and CAM-ICU9 . Inattention and the broad fluctuations of symptoms are characteristics not found in other psychiatric illnesses. At the same time, they are the most difficult to measure and identify. Attention is a complex phenomenon that involves distractibility, vigilance and concentration, and is our most basic interface with the environment. Unless patients are grossly agitated and irrational, the clinical expression of inattention can be very subtle. It is easily mistaken for the withdrawal and lack of environmental engagement found in depression. Fluctuations, unless they are marked, are often written off as fatigue, uncooperativeness, withdrawal, differing responses to different health
practitioners, or reactions to procedures. Given changeovers of physicians and nurses in busy hospitals, such indefinite characteristics go largely unrecognized unless staff nursing notes are carefully mined for evidence of these subtle changes. Nurses are the first to recognize early symptoms of delirium, although they do not reliably diagnose it as such, and are a rich source of descriptive information that can greatly assist with diagnosis10 . Broadly accepted subcategories include ‘active’, ‘mixed’, and ‘quiet’ delirium. These subcategories may have implications for prognosis or pathophysiology. Significant investigation of these subtypes has been done, although these have not yet provided clear implications for causality, prognosis or intervention. Active delirium is defined as a state marked by agitation, physically aggressive and often violent activity, hyperattentiveness (the inability to suppress responses to the environment or to internal states) and emotional lability. In this condition, deficits in focused attention and fluctuations of presentation are easily identified. Quiet delirium is defined as a state marked by withdrawal, lack of involvement in or communication with the environment, bland or flat affect, and a depressed level of consciousness short of frank stupor. These symptoms reflect an inability to attend appropriately and in sequential fashion to the demands of the environment. Mixed deliriums are considered to be a combination of the two. The prevalence of these subtypes is variably reported but averages 25% for quiet delirium, 45% for mixed delirium, and 30% for active delirium. All subtypes of delirium can present with motor symptoms (dysarthria, difficulty swallowing, gait disturbances), affective symptoms (dysphoria, lability, anxiety), sensory difficulties that are associated with incorrect cerebral processing of sensory data (clinically expressed as difficulties with hearing, appreciation of pain), and illusory phenomena, aphasia (partial or global) and impaired cognitive function (dysexecutive function, disorientation, nonsensical speech). Any of these symptoms may fluctuate, even within seconds. The appreciation and reporting of pain by the delirious patient is particularly problematic, as untreated pain can worsen delirium, yet overtreatment with narcotic agents can have the same result. Psychotic-like symptoms such as disorganized speech and visual hallucinations may also be associated, although the hallucinations in delirium are more illusory than hallucinatory. They commonly involve nonsensical images such as ‘clowns on bicycles’ or ‘tires in the ceiling’. The differentiation of delirium from prominent psychotic illnesses, including schizophrenia, schizoaffective disorder and bipolar disorder, can be problematic. Pre-existing psychiatric diagnoses are a principal cause of poor identification of
Principles and Practice of Geriatric Psychiatry, 3rd edn. Edited by Mohammed T. Abou-Saleh, Cornelius Katona and Anand Kumar 2011 John Wiley & Sons, Ltd
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PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRY Table 36.1 DSM-IV-TR diagnostic criteria for delirium A. Disturbance of consciousness (i.e. reduced clarity of awareness of the environment) with reduced ability to focus, sustain, or shift attention. B. A change in cognition (e.g. memory deficit, disorientation, language disturbance) or C. Development of a perceptual disturbance that is not better accounted for by a pre-existing, established, or evolving dementia. D. Disturbance develops over a short period of time (usually hours to days) and tends to fluctuate during the course of the day. E. There is evidence from the history, physical examination, or laboratory findings that the disturbance is caused by the direct physiological consequences of a general medical condition.
delirium, as the patients’ symptoms are often attributed to them11 . In these cases, reliance on clues from the patient’s clinical history is critical. Quietly delirious patients are frequently misidentified as depressed. Farrell and Ganzini12 found that 42% of patients referred to psychiatry consultation services for depression were actually delirious. However, an additional finding was that 60% of patients with delirium have symptoms of dysphoria, and 52% have passive or active thoughts of suicide. Acutely ‘suicidal’ patients suffering with prolonged hospitalizations and multiple medical problems are prototypically confusing. In such cases, the burden of risk and need for immediate medical intervention rest with delirium rather than depression. A further consideration is that symptoms of delirium present along a spectrum. Evidence for the existence of subsyndromal delirium has been presented by Levkoff et al., among others13 . Marcantonio et al. found that patients with subsyndromal delirium had worse outcomes than patients with diagnosable mild delirium14 . The recognition of delirium remains one of the most prominent problems in the field. The term ‘recognition’ includes not just diagnosis of the medical condition of delirium, but also the recognition that it is a severe illness that cannot be assumed to resolve on its own with few sequelae. Recent appreciation of this has led to skyrocketing numbers of publications in the field in recent years15 .
THE ETIOLOGY OF DELIRIUM Population at Risk A multitude of risk factors have been identified in treatment studies of delirium, often with little overlap. However, most would agree that age, cognitive impairment, medication and medical burden define the characteristics of the population at highest risk2 . Efforts to advance the field by seeking universal ‘causes’ of delirium have therefore been very frustrating. It is easiest to conceptualize the aetiology of delirium from the perspective of the syndrome of frailty. Frailty has many definitions, but on a physiological level its most commonly accepted conceptualization is sarcopaenia, or progressive deterioration of skeletal muscle16 . It is usually found in patients who are older, cognitively impaired and medically ill, and in fact the majority of patients who develop delirium are frail. Some investigators provide a broader view of the components of frailty by including socioeconomic stressors, psychiatric disorders, medication and
home environment as well as medical vulnerabilities, which reference the broad network of resources that frail geriatric patients require to avoid catastrophic illness17 . The increased vulnerability of frail patients to the catastrophic decline represented by delirium is related to their limited physiological reserve. With ageing, there is diminution of redundant systems such as neurons and neuronal circuits in the brain and excess metabolic capacity in the liver and kidney. Patients with the least reserve are more susceptible to any stressor, however small, than healthier individuals, in a striking resemblance to chemical equations far from equilibrium. The implication is that the patient’s underlying vulnerability and disequilibrated status (as opposed to any specific ‘last minute’ precipitating causes), are the most important predictors of delirium in an individual person. It is then easy to conclude that the prominent precipitating causes of delirium are the most common complications, including iatrogenic ones, found in hospitalized patients. A short list includes hyponatraemia, acute blood loss, pain, acute renal failure, fractures, acute infections (urinary tract or pulmonary), the use of longer term indwelling bladder catheters, dehydration, decubiti, malnutrition and the use of psychotropic medications2 .
Pathophysiology of Delirium Historically, multiple interacting theories have been proposed to explain the pathophysiology of delirium. Any given delirium may have an unknown number of associated clinical conditions (baseline and precipitating factors), and they do not necessarily occur in the same combinations. It is only when the patient has recovered that there is any clinical certainty that the basic physiological process(es) have been fully addressed. However, many deliriums do not fully resolve. It is also not necessarily the case that two patients who appear to have equal degrees of baseline and precipitating stressors will both become delirious. This lack of reproducibility has wreaked havoc with our investigations of pathophysiology. We are left with broad-based geriatric clinical intervention methods that are helpful but quite non-specific, and this may account for some of our difficulty in making progress in the field. At a cellular or molecular level, the most compelling evidence indicates that excess dopamine and/or insufficient acetylcholine in the brain could best explain the cascade of metabolic and behavioural complications of delirium. Each has complex and interactive impacts on cellular function within the CNS18 . Impairments in neuronal membrane function appear to underlie much of the pathophysiology of delirium. Neuroimaging has recently been incorporated to evaluate structural and functional processes in the brain during delirium, although the findings are diverse enough that consistent trends have so far been elusive. Yokota and colleagues, using xenon enhanced CT, found that patients with delirium experienced a 42% reduction in overall cerebral blood flow compared to baseline; after recovery from delirium, the findings normalized19 . Such findings may explain the multisystem deficits observed, which include cognitive, affective, sensory and motor function. There is not enough evidence at this time to determine whether structural correlates precede or follow delirium.
Major areas of exploration Inflammation
Inflammatory processes such as urinary tract infection, osteomyelitis and pneumonia, are highly associated with delirium. With ageing there is an elevated inflammatory profile20 . Activated glial cells transmit peripheral inflammatory cytokine
DEGENERATIVE AND RELATED DISORDERS responses to the CNS. This is associated with decreased synaptic plasticity, a necessity for the modulation of behaviour, learning and cognition20 . Inflammatory states as well as hypoxia and hypoglycaemia are associated with impaired mitochondrial function; this might support a hypothesis that disturbed function of endothelial cells could alter the blood–brain barrier. Release of the inflammatory cytokines TNF-alpha and interleukin-1 generates adhesion molecules that disrupt cerebral vasculature, further impacting the integrity of the blood–brain barrier20 . Extracellular glutamate in normal brain is quickly metabolized. However, in the presence of impaired mitochondrial function, hypoglycaemia hypoxia, and glucose, excess extracellular glutamate results in increases in cellular influx of Ca++ . This in turn leads to stimulation of NMDA receptors, which are excitotoxic2 . Intracellular Ca++ appears to be the main trigger of a series of reactions, including mitochondrial injury and activation of catabolic enzymes that lead to cellular dysfunction and potentially death. During states of cerebral ischaemia, further cellular risk is posed by efflux of dopamine. Use of barbiturates, isoflurane and etomidate, common agents associated with anaesthesia, may mitigate these responses2,21 . Few, if any, studies have linked the risk of delirium to the use of anaesthetic agents.
The acetylcholine hypothesis
Another principal theory involves decreases in the availability to brain cells of adequate amounts of acetylcholine (ACH). ACH is a fundamentally important neurotransmitter in areas serving attention and memory. Among multiple reports, surgical ICU patients with delirium had higher serum anticholinergic levels. A dose-related relationship was identified by Flacker et al.22 , who also identified higher levels of endogenous anticholinergic substances. A number of studies, although not all, have associated anticholinergic medications with delirium.
Impact of excessive dopamine
Another important hypothesis relates to increased extracellular dopamine. The influx of calcium into cells that occurs during hypoxic conditions in brain stimulates the activity of tyrosine hydroxylase. This results in increased production of dopamine, with resulting disruption of ATP production. Decreases in the production of ATP and the increase in toxic metabolites of dopamine then inhibit cathechol O-methyltransferase, the main extracellular deactivator of dopamine. These processes collectively result in increased dopamine levels in brain, up to a factor of 500× during episodes of striatal ischaemia5 . Further, dopaminergic neurons themselves are known to be highly susceptible to oxidative stress, which may result in massive releases of dopamine into the extracellular space5 . Agents that increase available dopamine in the brain, such as stimulants, have also been associated with delirium. D2 blockers such as haloperidol are widely known to improve behaviour in patients with delirium, and possibly the syndrome itself.
Other neurotransmitters The kinetics of neurotransmitters other than acetylcholine and dopamine are also highly sensitive to conditions of hypoxia and hypoglycaemia, as above. Disorders of release, synthesis and degradation of gamma-aminobutyric acid (GABA), serotonin (either in excess or insufficiency), as well as norepinephrine and glutamate, have been linked in various work to delirium5 . Cerebral oxidative metabolism, as well as cardiovascular and respiratory reserves that support it, decrease with ageing2 .
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Glycemic control Decreased availability of inhibitory neurotransmitters, deposition of neutrophils and mitochondrial damage are associated with poor glycaemic control. Improved glucose control with insulin (specifically) improves the CNS outcomes of critically ill patients21 . Molecular genetics
Efforts to link the presence of the APOE4 variant of this gene, which has been well established in association with Alzheimer’s disease, have resulted in mixed findings2 . It has been associated with increased duration of delirium in ICUs. Polymorphisms in DRD3 and the dopamine transporter SLC6A3 are the most commonly polymorphisms associated with delirium tremens20 .
THE IMPACT OF FOCUSED INTERVENTION TRIALS ON RECOGNITION AND MANAGEMENT A number of intervention programmes have been employed to address the severe long-term outcomes of delirium, which include death, dementia, increased lengths of stay, decreased function, rehospitalization and new institutional placement. These programmes have been studied in hospitalized patients; there are no published trials among outpatients. A number of these trials have found that they are not helpful for the primary outcome of a decrease in incidence23,24 . Other studies have demonstrated decreases in severity and duration of symptoms of delirium in hospital, both of which have been significantly associated with worsened outcomes. Unfortunately the impact of these interventions on longer term outcomes has been mixed and overall disappointing25 . In some cases this may be due to the limited time the patient is exposed to the intervention, e.g. when hospitalized as part of a pre-established protocol14 . In light of this, most studies conclude that prevention of delirium is the primary clinical goal. In a prominent study published in 199926 , a complex intervention that involved a significant amount of volunteer work as well as a very high level of nursing care was shown to significantly reduce length of stay, number of episodes and, finally, the incidence of delirium. This may have been due to the highly refined identification of risk factors in this population; Inouye distinguished baseline risk factors for delirium from risk factors for triggering of a new episode. Going forward, this two-phased risk assessment method has helped reshape our conceptualization of treatments for delirium by focusing on modifiable, new onset, precipitating risk factors. This innovation has improved our ability to intervene effectively in cases of delirium. Marcantonio performed a highly organized and comprehensive geriatric medicine programme that also demonstrated a decreased incidence of delirium in post-hip fracture patients14 . The work of both Inouye and Marcantonio, that has primarily focused on providing basic, but comprehensive care, has demonstrated that the interventions needed in delirium are most often not arcane or difficult to employ, and are largely inexpensive. These interventions highlight an effective level of geriatric care that could be attained in any institution.
DEMENTIA AND DELIRIUM Delirium is often confused with dementia. A critical part of the diagnosis of delirium involves identifying that the mental status presented
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by a patient is not the patient’s baseline level of cognition and that a relatively rapid change has taken place. Delirium is an acute, catastrophic response to an inciting medical event. The evolution of dementia is significantly more gradual in most cases. Where there is doubt, it is safest to address the clinical situation as a delirium so that any precipitating causes are addressed as soon as possible. The differentiation of these two clinical problems is complex because the precipitating cause(s) of the delirium may not easily be temporally connected with the onset of the syndrome of delirium itself. Patients with delirium superimposed on dementia had more than twice the risk of mortality at 12 months than patients with delirium alone, dementia alone or patients with neither27 . Assisted living facility residents classically have high rates of dementia and the relative risk of discharge of such patients back to institutional settings after an episode of delirium was 9.11 . There may be priming of the immune system as well. Patients with dementia are increasingly understood to have chronic inflammatory processes within the CNS. Acute systemic inflammatory processes that precipitate delirium may have been ‘primed’ by the underlying inflammatory process20 .
TREATMENT APPROACHES TO DELIRIUM Priorities of treatment include addressing acute medical contributors to the syndrome as well as stabilizing patient behaviour sufficient to enable the treatment of underlying medical causes. The primary task of clinicians is to identify and address modifiable conditions. In this way the impact of relatively unmodifiable conditions (such as stroke, myocardial infarction end stage renal function etc.) can be minimized. Our effectiveness at treating delirium depends on the extent to which we can provide skilled and sophisticated nursing care that allows time for the multiple interventions required by elderly patients. Avoidance of iatrogenesis that can prolong the delirium is an essential part of this effort. Factors contributing to increased risks of delirium in hospital include the increased pace of health care settings, rapid and increasingly unstable discharges and remarkably limited amounts of time spent with patients. Housestaff may have as little as 3.5 minutes per day per patient4 . Skilled nursing care alone could provide many of the most effective strategies for minimizing delirium, including mobilization, improvement of cognitive stimulation and minimization of the need for restraints. Up to 50% of cases of delirium can be prevented4 .
Pharmacological Approaches to Behavioural Stabilization The use of restraints can worsen delirium, as can the overuse of certain medications. Use of benzodiazepines, while standard for obligate alcohol detoxification regimens and for sedation in ICUs, has nonetheless been found in most studies to carry a high risk of inducing or significantly worsening delirium2 . There are few double-blinded, placebo-controlled, randomized trials of neuroleptics for behavioural management in delirium. Of all these agents, haloperidol remains the most studied. Haloperidol can be effective in low dosages, starting with 0.25 mg po or IM bid, and increasing to the 2–3 mg per day range only in severe cases. Risperidone in doses ranging from 0.5 to 4.0 mg daily and olanzapine in doses of 2.5–11.6 mg daily have been efficacious for the behavioural treatment of delirium with fewer extrapyramidal effects than haloperidol2 . In addition, case reports or case series regarding quetiapine, aripiprazole and ziprasidone have been published with no
randomized, double-blinded, placebo-controlled studies yet reported. There are very few such medication trials in the field.
Environmental Management for Behavioural Stabilization Patients with delirium are unable to manage their environment, make appropriate decisions or care for their basic needs, and they cannot problem solve. Therefore, the environment has to adapt to them. Most studies agree that decreasing the complexity of the environment by limiting rotation of personnel caring for the patient, minimizing room changes, providing rest and quiet at night time, feeding the patient, providing a calming ‘interpreter’ such as a ‘sitter’ or family member to reorient and guide the patient, limiting distractions (loud conversation, beepers, overhead speakers, televisions, crowded areas), providing hearing aids and glasses, and providing clear-cut and step-by-step instructions are critical. Mobilizing the patient will minimize recovery time, and also may have modulatory impacts on recovering muscle after a critical illness28 . Patients must be kept safe by limiting dangerous objects in their reach, avoiding falls and using assistive devices to limit the possibility of their pulling at lines or touching wounds. Complex protocols exist for the design of the treating environments that are beyond the scope of this chapter14 .
Treating the Causes
Acute medical conditions The basic principle of treatment of delirium is to aggressively seek and treat the reversible causes of delirium and to mitigate those that have little room for modulation. Emphasis should be placed on illnesses that result in poor cerebral oxygen availability or that are associated with significant metabolic impairments. Elimination of infectious or inflammatory sources, addressing orthopaedic injuries and removal of offending medications are also essential (see below). Given that most cases of delirium occur in the most vulnerable patients, correcting the most common metabolic and infectious factors, such as serum bun, creatinine, sodium and calcium, and treatment of urinary tract infections and pneumonia are remarkably effective interventions. Identification of metabolic trends by graphing laboratory values can be very helpful to determine original causes as well as indicators of further decline or recovery. Head imaging is not helpful in the absence of focal findings29 .
Removal of offending medications Removing offending medications, including opiates, anticholinergics, benzodiazepines and dopaminergics, is extremely important. Medications that alter the dopamine/acetylcholine balance within the CNS are a primary focus. A significant number of deliriogenic medications are found in commonly used medications, including digoxin, penicillin, amantadine, quinolone antibiotics, furosemide, nifedipine and warfarin. Further treatment of this topic is beyond the scope of this publication2 .
Pharmacological Approaches Historically, medications have been used to address behavioural problems, but recent evidence indicates that there may be some gains in disease modification.
DEGENERATIVE AND RELATED DISORDERS
Neuroleptics Recent work (see ‘Pathophysiology of Delirium’, above) suggests that the use of dopamine blockade is useful for disease modification. Agents that block dopamine have the potential to inhibit many neurotoxic events that occur in the presence of delirium, especially during conditions of hypoxia. Recent studies have focused on the usefulness of prophylactic antipsychotic use to diminish the incidence, severity or persistence of delirium. Kalisvaart was able to demonstrate decreased severity and persistence of delirium, although not incidence, among postoperative hip fracture patients by providing perioperative haloperidol use at 1.5 mg/day preoperatively and 3 days postoperatively. This was the first major study to demonstrate that pharmacological approaches could be used for disease modification30 . In another randomized, placebo-controlled, doubleblinded study of cardiac surgery patients, the incidence of delirium was quite significantly decreased when compared with placebo, even with a single dose of risperidone at 1 mg postoperatively31 . The use of neuroleptics as preventative or mitigating agents in delirium is not widespread at this time.
Cholinesterase inhibitors The use of cholinesterase inhibitors has been trialled in delirium. In a randomized, placebo-controlled, double-blinded study by Liptzin et al., the use was not found to have a significant impact on the incidence of delirium among young, relatively healthy patients undergoing elective hip fracture32 . In a small retrospective study, a population of dementia patients chronically maintained on rivastigmine had significantly less incidence of delirium than a comparable, nonchronically medicated group33 .
Dexemedetomidine The use of psychopharmacological agents to treat agitation in the ICU has been largely limited to propofol, which is an alcohol that is associated with hypotension and hyperlipidaemia, or to midazolam, which can suppress ventilatory effort and cause hypotension. Both have GABAergic effects that can worsen delirium. Fentanyl, an opiate IV for pain control and sedation, is also frequently utilized, either alone or in combination with propofol or midazolam, with attendant risks of dopaminergic/anticholinergic impacts. Dexemedetomidine, a very selective alpha-2 adrenergic agonist, has analgesic, sympatholytic, sedative and anxiolytic properties. It has increasingly been trialled as an alternative to the older protocols. In a randomized controlled trial of dexemedetomidine versus lorazepam in the ICU setting, while not significant, there was a dramatic difference in post-ICU mortality at 28 days and one year34 . Delirium is a critical illness that occurs primarily in elderly and frail individuals. Modulation of this very significant problem, however, is increasingly within our reach.
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3. Rockwood K, Cosway S, Carver D et al. The risk of dementia and death after delirium. Age Ageing 1999; 28: 551–6. 4. Inouye SK, Schlesinger MJ, Lydon TJ. Delirium: a symptom of how hospital care is failing older persons and a window to improve quality of hospital care. Am J Med 1999; 106: 565–73. 5. Maldonado JR. Pathoetiological model of delirium: a comprehensive understanding of the neurobiology of delirium and an evidence-based approach to prevention and treatment. Crit Care Clin 2008; 24(4): 789–856. 6. Bair BD. Frequently missed diagnosis in geriatric psychiatry. Psychiatr Clin North Am 1998; 21(4): 941–71, viii. 7. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th edn. Washington, DC: American Psychiatric Association, 1994, 129. 8. Inouye SK, Van Dyck CH, Alessi CA et al. Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med 1990; 113(12): 941–8. 9. Ely EW, Margolin R, Francis J et al. Evaluation of delirium in critically ill patients: validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Crit Care Med 2001; 29(7): 1370–79. 10. Steis MR, Fick DM. Are nurses recognizing delirium? A systematic review. Gerontol Nurs 2008; 34(9): 40–48. 11. Kishi Y, Kato M, Okuyama T et al. Delirium: patient characteristics that predict a missed diagnosis at psychiatric consultation. Gen Hosp Psychiatry 2007; 29(5): 442–5. 12. Farrell KR, Ganzini L. Misdiagnosing delirium as depression in medically ill elderly patients. Arch Intern Med 1995; 155(22): 2459–64. 13. Levkoff SE, Liptzin B, Cleary PD et al. Subsyndromal delirium. Am J Geriatr Psychiatry 1996; 4(4): 320–29. 14. Marcantonio ER, Flacker JM, Wright RJ, Resnick NM. Reducing delirium after hip fracture: a randomized trial. J Am Geriatr Soc 2001; 49(5): 516–22. 15. Meagher D. More attention, less confusion: time to lessen the burden of delirium. Int Rev Psychiatry 2009; 21(1): 1–3. 16. Morley JE, Haren MT, Rolland Y, Kim MJ. Frailty. Med Clin North Am 2006; 90: 837–47. 17. Rockwood K, Song X, MacKnight C et al. A global clinical measure of fitness and frailty in elderly people. CMAJ 2005; 173(5): 489–95. 18. Gunther ML, Morandi A, Ely EW. Pathophysiology of delirium in the intensive care unit. Crit Care Clin 2008; 24: 45–65. 19. Yokota H, Ogawa S, Kurokawa A, Yamamoto Y. Regional cerebral blood flow in delirium patients. Psychiatry Clin Neurosci 2003; 57(3): 337–9. 20. Godbout JP, Johnson RW. Age and neuroinflammation: a lifetime of psychoneuroimmune consequences. Neurol Clin 2006; 24: 521–38. 21. Harukuni I, Bhardwaj A. Mechanisms of brain injury after global cerebral ischemia. Neurol Clin 2006, 24: 1–21. 22. Flacker JM, Cummings V, Mach JR et al. The association of serum anticholinergic activity with delirium in elderly medical patients. Am J Geriatr Psychiatry 1998; 6(1): 31–41. 23. Pitkala K, Laurila JV, Strandberg TE, Tilvis RS. Multicomponent geriatric intervention for elderly inpatients with delirium: a randomized, controlled trial. J Gerontol A Biol Sci Med Sci 2006; 61(2): 176–82. 24. Cole MG, Primeau FJ, Laplante J. Systematic detection and multidisciplinary care of delirium in older medical inpatients: a randomized trial. CMAJ 2002; 167(7): 753–9.
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25. Milisen K, Lemiengre J, Braes T, Foreman MD. Multicomponent intervention strategies for managing delirium in hospitalized older people: systematic review. J Adv Nurs 2005; 52(1): 79–90. 26. Inouye SK, Bogardus ST, Charpentier PA et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med 1999; 340: 669–76. 27. Bellelli G, Frisoni GB, Turco R et al. Delirium superimposed on dementia predicts 12-month survival in elderly patients discharged from a postacute rehabilitation facility. J Gerontol A Biol Sci Med Sci 2007; 62(11): 1306–9. 28. Pustavoitau A, Stevens RD. Mechanisms of neurologic failure in critical illness. Crit Care Clin 2008; 24: 1–24. 29. Huschmidt A, Shabarin V. Diagnostic yield of cerebral imaging in patients with acute confusion. Acta Neurol Scand 2008; 118(4): 245–50. 30. Kalisvaart Kees J, deJonghe JFM, Bogaards MJ et al. Haloperidol prophylaxis for elderly hip-surgery patients at risk for delirium: a randomized placebo-controlled study. J Am Geriatr Soc 2005; 53: 1658–66.
31. Prakanrattana U, Prapaitrakool S. Efficacy of risperidone for prevention of postoperative delirium in cardiac surgery. Anaesth Intensive Care 2007; 35(5): 714–19. 32. Liptzin B, Laki A, Garb JL, Fingeroth R, Krushell R. Donepezil in the prevention and treatment of post-surgical delirium. Am J Geriatr Psychiatry 2005; 13(12): 1100–106. 33. Dautzenberg PL, Mulder LJ, Olde Rikkert MG, Wouters CJ, Loonen AJ. Delirium in elderly hospitalised patients: protective effects of chronic rivastigmine usage. Int J Geriatr Psychiatry 2004; 19(7): 641–4. 34. Pandharipande PP, Pun BT, Herr DL et al. Effect of sedation with dexemedetomidine vs lorazepam on acute brain dysfunction in mechanically ventilated patients: the MENDS randomized controlled trial. JAMA 2007; 298(22): 2644–53.
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The Nosology of Dementia Kenneth Rockwood Division of Geriatric Medicine, Dalhousie University, Halifax, NS, Canada
INTRODUCTION
DSM-IV-TR
Nosology is the classification of disease. How the syndrome of dementia has been classified has changed over the years. Recognizing that textbooks are commonly consulted because readers want pragmatic answers to questions, and that understanding nuances first requires understanding the basic facts, this chapter will begin with the current classification of dementia. A second section will provide some historical context. The third section will suggest some areas that remain to be understood or at least, settled on. The focus will be on understanding the basis for the definition of the syndrome of dementia, which historically has been rooted in the diagnosis of Alzheimer’s disease. Separate chapters for many of the other dementing disorders will deal with these in separate detail; here we focus on diagnostic criteria for Alzheimer’s disease, and how these have influenced the way in which dementia is understood.
The Text Revision of the Fourth Edition of the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-IV-TR) was published in 20001 . As with DSM-IV, it gives a general (syndromic) definition of dementia, but the actual dementia diagnostic codes are presented by subtype, based on presumed aetiology. These include Alzheimer’s disease, vascular dementia, and separate categories for dementia due to HIV disease, head trauma, Parkinson’s disease, Huntington’s disease, Pick’s disease, Creutzfeldt–Jakob disease, other general medical conditions, substance-induced persisting dementia, dementia of multiple aetiologies, delirium and dementia not otherwise specified. Within the classification of other general medical conditions are listed a variety of other problems. Some, such as structural brain lesions, including subdural haematomas, and brain tumours, are not infrequently encountered, as are dementia due to multiple sclerosis or to systemic lupus erythematosis. Others are less common, such as dementia due to endocrine disorders (e.g. hypothyroidism or hyperparathyroidism) and CNS infection (neurosyphillis, cryptococcus). Still others are often obscure disorders, such as Kuf’s disease and adrenoleukodystrophy. Note, too, that dementia due to Lewy bodies can be classified in DSM-IV-TR as due to ‘other general medical conditions’ (or as Parkinson’s disease dementia; DSM-IV-TR is in this way up to date in noting controversy over whether Lewy body dementia and Parkinson’s disease dementia are aspects of the same disorder, or usefully separable)8 – 10 . Frontotemporal dementia, a broader classification than the not unproblematic Pick’s disease, can also be recorded under dementia to other general medical conditions. Although dementia is diagnosed by aetiology, the syndromic aspects said to be ‘essential’ are repeated for each type. In the criteria for ‘Dementia of the Alzheimer’s Type’ (Table 37.1) these are items A, B, C and E. Item D is adapted to be more disease-specific for each separate dementia classification. Note that DSM-IV-TR maintains the development of DSM-IV in that memory impairment is not further delineated, whereas in DSM-IIIR, impairment had to be demonstrated in both so-called short- and long-term memory.
CURRENT NOSOLOGY OF DEMENTIA At present, three references – DSM-IV-TR1 , ICD-102 and the NINCDS-ADRDA3 criteria – provide authoritative approaches to the nosology of dementia. Each is rooted in the formulation codified in an influential textbook by Lishman4 , which proposed that dementia was a global cognitive impairment (memory plus other cognitive features) that was sufficiently severe to interfere with social or occupational function. The newly developed 10/66 criteria, discussed below, have drawn attention to difficulties in the operationalization of the idea that the cognitive impairment must be severe enough to interfere with function, and it may be that their approach will become increasingly influential5 . Similarly, although largely technically infeasible in the low- and middle-income countries being studied by the 10/66 group, another influential proposal suggests that clinical features beyond demonstrable memory impairment count for little, compared with biomarkers6 . How these newer trends will play out is not clear. As a syndrome, dementia must be differentiated from other syndromes in which cognition is (or can be) impaired, including delirium, depression and age-associated cognitive decline. This last is variably conceptualized. Each of the syndromes in which cognition is impaired, but which the cognitive impairment does not meet criteria for dementia, forms part of what has been referred to as ‘cognitive impairment, no dementia’ (CIND). The prevalence of the heterogeneous group of disorders that is CIND is estimated to be about twice that of the prevalence of dementia7 .
ICD-10 Chapter V of the 10th revision of the International Classification of Diseases (ICD-10) is the World Health Organization’s codification of
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PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRY Table 37.1 DSM-IV-TR diagnostic criteria for dementia of the Alzheimer’s type A. The development of multiple cognitive deficits manifested by both (1) memory impairment (impaired ability to learn new information or to recall previously learned information) (2) one (or more) of the following cognitive disturbances: (a) aphasia (language disturbance) (b) apraxia (impaired ability to carry out motor activities despite intact motor function) (c) agnosia (failure to recognize or identify objects despite intact sensory function) (d) disturbance in executive functioning (i.e., planning, organizing, sequencing, abstracting) B. The cognitive deficits in Criteria A1 and A2 each cause significant impairment in social or occupational functioning and represent a significant decline from a previous level of functioning. C. The course is characterized by gradual onset and continuing cognitive decline. D. The cognitive deficits in Criteria A1 and A2 are not due to any of the following: (1) other central nervous system conditions that cause progressive deficits in memory and cognition (e.g., cerebrovascular disease, Parkinson’s disease, Huntington’s disease, subdural hematoma, normal-pressure hydrocephalus, brain tumor) (2) systemic conditions that are known to cause dementia (e.g. hypothyroidism, vitamin B or folic acid deficiency, niacin deficiency, hypercalcemia, neurosyphilis, HIV infection) (3) substance-induced conditions E. The deficits do not occur exclusively during the course of a delirium. F. The disturbance is not better accounted for by another Axis I disorder (e.g. Major Depressive Episode, Schizophrenia). Additional coding, based on presence or absence of a clinically significant behavioral disturbance: 294.10 Without Behavioral Disturbance: if the cognitive disturbance is not accompanied by any clinically significant behavioral disturbance. 294.11 With Behavioral Disturbance: if the cognitive disturbance is accompanied by a clinically significant behavioral disturbance. (e.g. wandering, agitation) Specification of subtype: With Early Onset: if onset is at age 65 years or below With Late Onset: if onset is after age 65 years Source: DSM-IV-TR: Text Revision of the fourth edition of the Diagnostic and Statistical Manual of the American Psychiatric Association.
diagnoses in relation to ‘mental and behavioural disorders’. Dementia is included as a so-called ‘organic’ mental disorder (Table 37.2). The ICD-10 manual states that ‘Dementia (F00-F03) is a syndrome due to disease of the brain, usually of a chronic or progressive nature, in which there is disturbance of multiple higher cortical functions, including memory, thinking, orientation, comprehension, calculation, learning capacity, language, and judgment. Consciousness is not clouded. The impairments of cognitive function are commonly accompanied, and occasionally preceded, by deterioration in emotional control, social behaviour, or motivation’ (Table 37.2). Its emphasis on impaired behaviour is noteworthy, although in practice this might not be operationalized as distinct from the impaired ‘social functioning’ seen with DSM. Like DSM-IV-TR, the ICD-10 classifies dementia into an early onset, before age 65 years, and a late onset, after age 65 years. ICD-10 suggests that the early-onset form should have a more rapid onset and progression than the late-onset form. In general, however, in both DSM-IV and ICD-10, the validity of subgroups of dementia has often been found lacking, at least as employed in routine clinical use11 . The differences in how dementia is operationalized are not inconsequential. Even the minor differences between standard criteria can importantly influence prevalence rates12,13 , especially at very late ages14 . In general, ICD-10 has been reported to be less sensitive than earlier versions of the DSM criteria, although that is not always the case15,16 .
NINCDS-ADRDA Even though the diagnostic classification proposed in this 1984 report focuses on Alzheimer’s disease, the consensus diagnostic criteria proposed by the National Institute of Neurological and Communicative
Table 37.2 ICD-10 criteria for dementia. Definition of dementia in the ICD-10 (adapted) G1 There is evidence of each of the following: (1) A decline in memory (at least) sufficient to interfere with everyday activities, though not so severe as to be incompatible with independent living (2) A decline in other cognitive abilities characterized by deterioration in judgement and thinking, such as planning and organizing, and in the general processing of information (at least) sufficient to cause impaired performance in daily living, but not to a degree that makes the individual dependent on others G2 Awareness of the environment (i.e. absence of clouding of consciousness) G3 There is a decline in emotional control or motivation, or a change in social behaviour manifest as at least one of emotional liability, irritability, apathy or coarsening of social behaviour G4 The symptoms in criterion GI should have been present for at least 6 months
Disorders and Stroke, and the Alzheimer’s Disease and Related Disorders Association (NINCDS-ADRDA) has served for many years as the standard for a diagnosis of Alzheimer’s disease, and its definition of dementia was also normative3 . It still heavily influences how research on dementia is conducted, especially as it makes up the usual inclusion criteria for drug trials on Alzheimer’s disease (Table 37.3). The original criteria have been adapted somewhat – dementia can be diagnosed with the aid of cognitive screening instruments other than
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Table 37.3 NINCDS/ADRDA criteria for Alzheimer’s disease Criteria for clinical diagnosis of Probable AD include: Dementia established by clinical exam and documented by MMSE or Blessed Dementia scale, confirmed by further neuropsychological tests. Deficits in two or more areas of cognition. Progressive worsening of memory and other cognitive functions. No disturbance of consciousness. Onset between the ages of 40 and 90. Absence of systemic diseases or other brain diseases that could explain the cognitive changes. The diagnosis of Probable AD is supported by: Progressive deterioration of specific cognitive functions such as language, motor skills, and perception (aphasia, apraxia, agnosia, respectively). Impaired activities of daily living. Positive family history, particularly if documented neuropathologically. Lab results: Normal lumbar puncture, EEG, and evidence of cerebral atrophy on CT or MRI. Clinical features consistent with diagnosis of Probable AD, after exclusion of other causes of dementia: Plateaus in clinical course. Associated symptoms: depression, insomnia, incontinence, delusions, illusions, hallucinations, catastrophic verbal, emotional, or physical outbursts, sexual disorders, and weight loss. Other neurological abnormalities in some patients, especially with more advanced disease and including motor signs such as increased motor tone, myoclonus, or gait disorder. Seizures in advanced disease. CT normal for age. Features that make the diagnosis of Probable AD unlikely or uncertain: Sudden apoplectic onset. Focal neurological findings such as hemiparesis, sensory loss, visual field deficits, and incoordination early in the course of the illness. Seizures or gait disturbances at the onset or very early in the course of the illness. Clinical diagnosis of Possible AD. May be made on the basis of the dementia syndrome, in the absence of other neurologic, psychiatric, or systemic disorders sufficient to cause dementia, and in the presence of variations in the onset, in the presentation, or in the clinical course. May be made in the presence of a second systematic or brain disorder sufficient to produce dementia, which is not considered to be the cause of the dementia. Should be used in research studies when a single, gradually progressive severe cognitive deficit is identified in the absence of other identifiable cause.
the Mini Mental State Examination (MMSE)17 or Blessed Dementia Rating Scales18 , and neuropsychological confirmation is not always required. But the key points of a probable cause being the case for a clinical diagnosis, neuropathology providing the definition reference, and the diagnosis being only possible when other disorders are present operate still, even though each is far from an indubitable proposition19 . Over the years, many proposals have been made for how Alzheimer’s disease might be subtyped other than by age at onset. For example, rapidity of progression, focality of onset, presence of additional features such as early extrapyramidal signs each has had adherents, but none has made their way into standard criteria19 .
SOME HISTORICAL CONTEXT FOR THE CURRENT CLASSIFICATION Dementia as a clinical syndrome has for a long time been distinguished from changes that are often seen as people age – especially problems with memory. Even in the last 30 years, however, there have been major changes in how dementia is conceptualized, and to a large extent these are reflected in ICD-10 and DSM-IV-TR. In the early years of the modern era, much effort was put into making clear that dementia was distinct from normal ageing. Even so, ICD-10 still has a conceptually ancient hold-over in the diagnostic
code (Code R54) of ‘senility without mention of psychoses’, found in a chapter entitled ‘The development of more clinically meaningful outcome measures and laboratory findings, not elsewhere classified’. This code can still appear in certain administrative tabulations, and has the advantage of also being in ICD-9, so that under those circumstances it can allow for the evaluation of trends. Still, the ‘senility’ diagnosis generally represents an outmoded, obsolete and offensive understanding of dementia – as somehow ‘normal’ ageing – that has no place in modern care. Early in the modern era – roughly from the late 1950s, and especially following a series of articles in the mid-to-late 1960s by Martin Roth and colleagues20 – 24 , a lot of work was put into distinguishing between the neurodegenerative and vascular causes of dementia. They sought to repudiate the view that ‘senility’ was due to ‘hardening of the arteries’ and made the case that the changes in cognitive performance in elderly people was a result of plaques and tangles – Alzheimer’s disease – or stroke – ‘multi-infarct dementia’. While this was true, we have come to understand that the wall between the two is porous – that vascular risk factors are also a risk for Alzheimer’s disease, and that the two commonly occur – even in the original series of cases from Newcastle25 –and can act synergistically (although this last point is disputed)26 – 29 . The early descriptions were correct in emphasizing how dementia affected the personality of an individual, through the undoing
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of what later would be called executive function. For example, a 1971 description of the clinical symptomatology of dementia warned against putting too much emphasis on ‘impaired memory and orientation’ as an ‘undue emphasis on these features may . . . obfuscate the richness of the clinical symptomatology. . . . an early and frequent complaint is that the patient is “not himself”, meaning that the patient and his companions have noted the onset of illness in terms of changes in function that are quite specific to that particular person, whether described in terms of alteration of drive, mood, enthusiasm, capacity to give and receive affection, creativity or other features’30 . As later – and comparatively recent – calls for an appreciation of the importance of executive function in dementia have made clear31,32 , these descriptions were largely lost soon thereafter. Instead, the view that Alzheimer’s disease was predominantly a disorder of memory, that temporal and parietal involvement was early, that frontal lobe involvement was late, and that the standardization offered by psychometric testing would trump the subjectivity of clinical judgement each contributed to the systematic lack of attention to ‘what makes a patient him[her]self’. Another point seen in earlier iterations of dementia criteria that is less commonly emphasized now is that a diagnosis of dementia should only be made in patients in whom consciousness was ‘clear’. This was meant to be another way of saying that consciousness should not be clouded, which in DSM-III was seen as a major distinguishing feature of delirium. (In DSM-IV-TR, delirium is again conceptualized as a disorder of consciousness; the only reference that it be clear, however, is the description of ‘reduced clarity of awareness of the environment’.) With the recognition of the importance of alterations in levels of consciousness as a hallmark of Lewy body dementia, however10 , this particular requirement has been dropped. Instead, the criteria make reference to the cognitive disorder not being better accounted for by delirium.
FUTURE CHALLENGES IN DEMENTIA NOSOLOGY The exciting pace of development in the study of dementia means that the field has to look anew at received wisdom. A large number of developments are likely to impact on what will be controversial about the nosology of dementia when the next edition of this textbook appears. Here, a few are sketched out in the barest detail. Even so, they give some hint as to why this most staid of topics is likely to have interest for some time yet.
‘Alzheimerization’ of Dementia Criteria Current dementia criteria are, as we have seen, largely modelled on the dementia characteristically seen in Alzheimer’s disease. This is a problem for dementias in which memory impairment is not the chief early manifestation. The two most commonly occurring examples are frontotemporal dementia and vascular dementia, especially the so-called ‘subcortical’ variant33 . In either, affective and behavioural disturbances can predominate early. The consequences of this problem are many. In the case of vascular dementia, Hachinski has long drawn attention to the opportunities missed in dementia prevention34 and in understanding the impact of vascular disease on brain function by underestimating its burden in the wait for memory to become impaired. In consequence, he has proposed the concept of vascular cognitive impairment35 . Over time, this has had great influence36 , but has yet to be reflected in the standard criteria, including in the NINDS-AIREN criteria for vascular dementia37 .
The presentation (and evaluation) of impaired judgement in someone whose memory is reasonably intact can be problematic, especially where social conduct violates legal norms (e.g. theft, sexual impropriety). In some cases, it is clear that a reliable clinical diagnosis of dementia can be made due to other characteristic features in the patient’s cognitive profile and how that impacts on function, even if memory is relatively intact. Even so, depending on the literalness of local prosecutors, the understanding that the criteria in real life often are only approximate can be a tricky business. (In such cases, where it is necessary to show that the criteria need not always be applied strictly, I have found it useful to cite Aristotle – who hedged that in biology rules apply ‘always or for the most part’38 . If that seems a bit obscure, it is always possible to resort to the usual disclaimer for hair loss products: ‘Your results may vary’.) Notwithstanding the incompleteness of the criteria, there are other circumstances of late-onset aberrant behaviour, coupled with some evidence of executive dysfunction, in which only the passage of time and progression of the illness to include other dementia features makes the diagnosis clear.
Cognitive Disturbances with Many Causes Dementia occurs largely in older people who are more likely to have things wrong with them. In consequence, in clinical practice it is common to encounter patients with many things wrong that might contribute to cognitive impairment. For this reason, dementia diagnostic criteria need to give particular attention to how such problems are to be conceptualized and identified. This is relevant in three situations. ‘Mixed dementia’ refers to co-existing illnesses and especially to the combination of infarction (or, more controversially, ischaemia) with Alzheimer’s disease. As noted, given that vascular risk factors are also risks for Alzheimer’s disease, not unexpectedly the two often conclude and can be the most common form of dementia encountered26 – 29,39, . In the ICD-10, NINCDS-ADRDA and NINDS-AIREN criteria, the result is a ‘possible’ diagnosis – e.g. ‘possible Alzheimer’s disease, with vascular component’. By contrast, DSM-IV-TR allows for ‘Dementia due to multiple etiologies’. (From a coding standpoint, multiple codes are allowed – i.e. each of the codes for the given causes is recorded.) A similar situation occurs when delirium complicates dementia. Again, this is a common situation, as each is a risk for the other40 . In addition, delirium which does not resolve is a risk for dementia, and results in an indeterminate period (of between 3–6 months) when features of both may be present41 . The multiple coding approach and the use of codes for delirium-complicating dementia seen in DSM-IV are considered a good way to handle the common co-occurrence of these syndromes, resulting in a proposal that ICD-11 should follow the lead of the DSM40,42 . The parallel is also seen when depression complicates dementia43 .
Lessons from the 10/66 Experience The 10/66 Dementia Research group is a collective of dementia researchers worldwide, who are carrying out population-based studies of dementia44 – 46 . The title refers to the fact that two-thirds of people with dementia live in low- and middle-income countries and that 10% (or less) of population research is conducted there. An early and important finding of the 10/66 was how poorly standard dementia criteria applied in many parts of the world. In consequence, the 10/66 group developed its own. These criteria differ from the
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standard criteria chiefly in how they operationalized the impact of cognitive impairment on function (relying less on informant reports of decline) and in the use of detailed procedures for operationalization, which were cross-culturally validated. These criteria yielded results that were both more consistent across sites and strikingly higher than those using DSM-IV dementia criteria (e.g. 10/66 criteria suggested prevalence of 5.6–11.7% by country, compared with 0.4–6.4%)5 . These last results raised the question of whether the criteria were too sensitive, and thereby not specific enough, or whether 10/66 ‘pathologizes’ mild decline that can be accommodated within many cultures in which less cognitive demand is placed on elders. These questions remain to be resolved.
inform criteria. Even so, it offers a way to retrieve some of the lesson taught by Wells (i.e. the warning that too much emphasis on easily testable cognitive elements might obscure the richness of the clinical symptomology). The approach to this problem that I have used with colleagues is known as goal attainment scaling51 , about which independent reviews suggest it has promise, but needs additional work, chiefly replication and some standardization52,53 . Whether the results of partially treated (or partially prevented) Alzheimer’s disease will be stable enough and common enough to warrant special categorization is a development to be evaluated with some interest.
Alzheimer’s Disease without Dementia
The nosology of the dementia syndrome is likely to continue to evolve, reflecting developments in how and where dementia is studied. Important challenges to our understanding of dementia reflect continuing development of our knowledge of these dread illnesses.
At a different spectrum from those who look to diagnose dementia in low- and middle-income countries are groups who are aiming to develop preventive treatment for dementia, or at least ones which could be implemented as early in the disease course as possible6 . For such groups, the interest is on how to couple the earliest manifestations of dementia with biological markers of the disease. Drawing on a body of work about very early47 and prodromal Alzheimer’s disease, and on the apparent promise of biomarkers, a consortium has proposed that biomarkers, coupled with a memory complaint, should form the basis for a diagnosis of Alzheimer’s disease. The clear intent is to provide a test base of people who are at high risk for the development of ‘full-blown’ Alzheimer’s disease, and to see if new interventions might prevent that outcome. How such a proposal will affect more widespread diagnosis of dementia is uncertain. Whether ‘prevented Alzheimer’s disease’ will look like ‘no (or mild) cognitive impairment’ is also uncertain, but the parallel case might exist now for successfully treated Alzheimer’s disease (below).
Executive Dysfunction As noted, it had been the case that, central to a clinical diagnosis of dementia, was the loss of aspects of an individual’s character which made them essentially themselves. This notion largely was lost for a period, before being rediscovered, under the guise of executive function. While the emphasis on executive function is welcome, it is not at all clear that the usual remedy (to employ measures of ‘frontal lobe tests’) addresses the clinical phenomenon sufficiently well. A cultural bias is at work in rejecting the characterization of an individual’s complaints – what makes dementia a problem for them – as too subjective an evaluation process, and instead substituting finger-tapping or clock-drawing tasks as preferable alternatives. Future criteria will need to examine how they view the notion of subjectivity or objectivity. In this, they might be helped by consultation with philosophers who understand the distinctions that are at play here.
Successful Treatment of Dementia Even though no current treatment cures Alzheimer’s disease, many people can be treated successfully, to the extent of having important overall improvement on global clinical measures48 . Evaluations of the notes from patient interviews in which clinicians rated patients as showing overall improvement have shown that typically in such cases some symptoms improve, most are stabilized and some worsen49,50 . In short, successful treatment can result not in cure, but in a new state. This state has yet to be operationalized in any terms that could
SUMMARY
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Epidemiology of Dementia Mary Ganguli University of Pittsburgh School of Medicine and Graduate School of Public Health, WPIC, Pittsburgh, PA, USA
Epidemiology has traditionally been the study of the distribution and determinants of disease in the population. Its principles and approaches are also used to study normal variation, for example changes related to normal ageing in the population at large. Epidemiology helps clinicians by acquainting us with the proportions of given populations that are affected by the conditions we diagnose and treat; the frequency with which different conditions, changes and outcomes occur; and the factors that raise and lower the probability of these conditions occurring. Importantly, epidemiology also completes the clinical picture of disease, demonstrating that patients who seek our services for a given condition are not typical of all individuals in the community with that condition. For example, individuals with dementia who present to a psychiatric clinic may have different characteristics (insight, symptoms, severity, duration, support) than those who are seen in neurological or general practice settings, or who do not seek clinical services at all. As of this writing, efforts are under way to revise the current clinical diagnostic criteria for dementia and its subtypes, including Alzheimer’s disease, in the World Health Organization’s International Classification of Disease1 and the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders2 . More than in previous editions, attention is being paid to epidemiological data that bear on diagnosis: for example, the heterogeneity of dementia and cognitive impairment, and the predictive validity of various diagnostic criteria in population settings.
BASIC DEFINITIONS Prevalence is a cross-sectional snapshot of the disease burden of the population. It is the proportion of individuals in a defined population who have the disease or condition at a given time (point prevalence) or defined period (period prevalence), regardless of how long these individuals have had the condition. Incidence is the rate at which new disease occurs in the population. It is the proportion of individuals previously free of disease who develop the disease during a defined period (e.g. one year, or 1 000 person-years), within a defined population. Overall prevalence and incidence estimates (e.g. for everyone aged 65 years and older) are less useful than age-specific estimates, that is, within defined age groups, such as those aged 65–74, 75–84 and 85+ years.
Prevalence is the product of incidence rate and duration of survival with disease. Thus, high prevalence can be the result of high incidence, long duration, or both. Two groups can have the same dementia incidence, with prevalence being higher in the group in which people with dementia live longer.
GLOBAL AGEING, DEMOGRAPHIC TRANSITION, DEVELOPED VS. DEVELOPING COUNTRIES The world’s population is ageing, as improving living standards have increased life expectancy across the globe. The most affluent countries have the longest average life expectancy, and the greatest proportions of older adults. However, population ageing is occurring faster in the low- and middle-income (‘developing’) countries than in the wealthier (‘developed’) countries. It is determined by both birth rates and death rates. Populations with high fertility tend to have low proportions of older people, and vice versa. The ‘demographic transition’ is the process in which, over time, a high-fertility-high-mortality population becomes a low-fertility-low-mortality population, and its average age increases. As people live longer, the public health concern becomes whether their years of extended life are characterized by relative health and independence or by ill-health, disability and dependence on others. Thus, we measure not only overall life expectancy but healthy life expectancy and disability rates. In affluent countries, disability rates appear to be decreasing as the population ages. In low- and middle-income countries, it seems likely that disability rates will climb as people live longer with chronic disease. The least affluent countries are the least prepared to deal with the challenges of population ageing, given the rapidity with which the demographic transition is occurring in their societies. However, one factor in their favour is the elderly support ratio, which is the number of elderly people for every 100 younger adults in a given population, with younger individuals assumed to be directly or indirectly supporting older ones. This ratio is increasing rapidly in the affluent countries, with greater numbers of older individuals needing support from a shrinking number of younger persons. In the less affluent countries, this ratio is expected to change quite slowly3 . Dementia is a major cause of functional disability, dependence and mortality in the elderly. It therefore reduces both overall life expectancy and active (disability-free) life expectancy, although the extent to which it does so might vary across populations. Dementia is also responsible for increasing use and cost of health services,
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particularly long-term-institutional care, in countries where such institutions are available and culturally acceptable. The cost to a given society of caring for its members with dementia depends on its age structure, the numbers and proportions of affected individuals, their length of survival and degree of dependency, the availability of appropriate goods and services, and who bears the costs of these items. These direct costs, as well as indirect costs (e.g. loss of income by the patient and family caregiver) will vary according to the affluence and age structure of a given society.
SYNDROMAL DEFINITION OF DEMENTIA: DSM, ICD, EVOLVING CRITERIA; ‘CASENESS’ At the time of this writing, the most widely employed diagnostic criteria for dementia at the syndrome level are those of the Tenth Revision of the International Classification of Diseases (ICD-10)1 and the Fourth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR)2 . Over the years, studies in different countries have used different versions of these criteria. Variations in definitions and criteria can potentially raise and lower estimates of prevalence and incidence across studies and populations. One study demonstrated that the proportion of individuals classified as having dementia varied from 3% using the ICD-10 criteria to 29% using the DSM-III criteria, within the same population4 . According to current definitions, dementia is a syndrome of acquired, chronic cognitive impairment, occurring in clear consciousness, sufficient to interfere with social and occupational functioning, and characterized by impairment in at least two cognitive domains. For the past few decades, the definition has further required that memory be one of the impaired domains2 , but this requirement may not persist in future revisions of diagnostic criteria. For example, it may be possible that an individual with significant impairments in executive and language functioning can be diagnosed as having dementia, even without memory impairment. Further, there is currently no standard diagnostic entity reflecting a minor level of cognitive decline that is not accompanied by functional impairment, thus falling short of the threshold for being called dementia. This situation too may change as knowledge evolves and preclinical detection of dementing illnesses becomes a possibility. Besides the functional dimension of the diagnosis, the standard neuropsychological criteria for dementia typically require test performance in two cognitive domains to be at least two standard deviations below the mean for the individual’s peer group, as defined by age, education, linguistic/ethnic group and sometimes gender. However, appropriate norms are not always available. Thus, the issue of ‘caseness’, or what makes an individual a true case, has yet to be universally defined, and will become harder as the demand increases for earlier detection of the dementia syndrome.
DEMENTIA SUBTYPES AND THE ROLE OF CO-MORBIDITY Alzheimer’s disease (AD) is a primary neurodegenerative disease which appears to be the single most common cause of the dementia syndrome in older adults, in most populations which have been studied worldwide. The next single most frequent cause of dementia is cerebrovascular disease; either cortical infarcts or white matter disease, or both, can lead to significant cognitive impairment and decline. Diagnostic criteria for vascular dementia and cognitive
impairment have varied as to whether the mere presence of cerebrovascular disease with dementia is sufficient, or whether evidence from neuroimaging is also required, for the diagnosis2,5 . However, mixed Alzheimer’s and vascular pathology is more common than pure vascular disease or pure degenerative disease, as borne out by the few community studies that have been able to conduct autopsies6 . Although prominent in specialty clinical settings, dementias related to other primary brain disorders such as frontotemporal lobar degeneration, Lewy body disease and Parkinson’s disease appear relatively infrequent in the community at large; population-based estimates are scarce. Opinion is moving towards accepting co-morbidity and multiple causes in a given individual with dementia, rather than selecting one subtype over another in the presence of mixed aetiology.
PREVALENCE AND INCIDENCE OF THE DEMENTIAS The overall prevalence of dementia, based on many studies in affluent countries worldwide, is in the range of 5–10% of individuals aged 65 years and older. One meta-analysis showed a doubling of dementia prevalence with every 5-year increase in age; for AD the doubling occurred with every 4.5 years and for vascular dementia every 5.3 years7 . Population studies typically do not employ neuroimaging or neuropathology for diagnosis, but rather use operationalized standard clinical diagnostic criteria. In these studies, AD appears to account for two-thirds to three-quarters of observed cases. Previous reports of vascular dementia being more prevalent than degenerative dementia in some Asian populations may have been the result of varying diagnostic criteria. However, prevalence has not been established for the newer, broader entity called vascular cognitive impairment (VCI) which encompasses all levels of cognitive decline from mild deficits to dementia. The prevalence of dementia of Parkinson’s disease has been estimated at about 0.5% of the population aged 65 years and older8 . Although incidence rates vary, one meta-analysis showed rates of AD ranging from 0.33% per year for those aged 65–74 to 8.68% for those aged 95+ years9 . Evidence is inconclusive as to whether incidence continues to increase after age 90. In a study including MRI scans for the diagnosis, the age-adjusted incidence rate for AD was 19.2, and for vascular dementia 14.6, per 1000 person-years10 . While many studies have shown higher dementia prevalence among women, many incidence studies have not shown a gender difference. If incidence is indeed the same in men and women, gender difference in prevalence may be due to longer survival in women. There are few population-based data on early-onset dementias. Based on a handful of studies from Asia, Africa, Central and South America, and Eastern Europe, prevalence in low- and middle-income countries is much lower than in the affluent countries. It is, however, increasing as their populations age, and seems to be divided between Alzheimer’s and vascular subtypes as in the rest of the world11 . The prevalence difference is not solely a function of life expectancy. Opinion is divided as to how much of the discrepancy is due to misclassification, given the difficulties in measurement discussed earlier, and how much reflects true differences in disease occurrence. However, all studies report an exponential increase in both prevalence and incidence with age. With the rapid population ageing of the less affluent countries, among which India and China have very large populations, even a lower proportion affected by dementia will reflect a larger number of individual cases in these countries than in the wealthier countries12 .
DEGENERATIVE AND RELATED DISORDERS
NORMAL VS. ABNORMAL COGNITIVE AGEING To differentiate early dementia from the cognitive changes of normal ageing can be challenging in clinical practice, and is no easier at the population level. The majority of older adults experience some slowing of information processing as part of normal ageing. Memory, visuospatial ability and executive functioning/reasoning also are likely to decline with normal ageing. In contrast, verbal/language abilities tend to remain more stable. Terms such as age-associated memory impairment and age-related cognitive decline have been used to characterize the cognitive changes of normal ageing. Terms including mild cognitive impairment (MCI)13 and cognitive impairment, no dementia (CIND)14 are used to describe states intermediate between normal cognitive ageing and dementia, where individuals experience or exhibit cognitive deficits greater than expected for age, without fulfilling diagnostic criteria for dementia. The prevalence of this variably defined intermediate state in the elderly population is entirely dependent on the definition, and has been shown to vary from 3 to 20% as a function of the criteria employed15 . The key element is mild cognitive decline with little or no functional change. This state frequently but not inevitably progresses to dementia. The rate of progression to dementia is reported as 12–15% per year in patients actively seeking care for memory problems in specialized settings like memory disorders clinics. The rate is lower in the community at large, when MCI is systematically detected by standardized assessment. In fact, MCI in the community appears to be an unstable and heterogeneous state with many individuals remaining stable or even reverting to normal over time. This discrepancy is inadequately understood, but suggests that it is premature to assume that MCI uniformly represents preclinical dementia. Outside specialty clinical settings, other conditions (e.g. anticholinergic medication effects, depression, heart failure) may contribute substantially to the observed impairments. It is likely that the criteria will undergo further refinement to enhance their predictive validity, possibly by including reliable biomarkers of underlying disease. It must be firmly recognized that no test of cognitive function is entirely free of the effects of culture and education. Individuals of greater age and lesser education will typically perform worse on most neuropsychological tests than younger and better-educated persons. If not carefully accounted for, these factors can lead to misclassification error in epidemiological studies, potentially inflating prevalence estimates of cognitive impairment and dementia in populations with low literacy and education.
CROSS-CULTURAL ISSUES IN DIAGNOSIS AND EPIDEMIOLOGY With some caveats, the process and functional consequences of brain ageing are assumed to be fairly similar in all populations, while their personal and social impact may not be the same across societies and cultures. Thus, the clinical thresholds may be different, or the same underlying disease biology may cross the clinical threshold to different extents in different populations. This variation can give rise to varying estimates of prevalence and incidence. Such estimates are also influenced by variation in life expectancy, the presence of co-morbid medical conditions, and local norms and expectations. In many cultures, cognitive impairment is considered an inevitable consequence of ageing, and expectations of the elderly are tailored accordingly. It may be the norm for younger family members to
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assume most of the older adult’s previous responsibilities other than basic self-care. Consider the examples of two older men with AD, one living in a large extended-family setting on a farm, and the other living alone in an urban apartment. Compared to the latter, the former may have to suffer a greater degree of cognitive impairment, and reach a more advanced stage of dementia, before he experiences interference with his own social and occupational functioning or the family reports a problem, resulting in a later diagnosis of dementia. Meanwhile, the second man’s environment requires him to independently use household appliances, and manage his own meals, finances and transportation; a lesser degree of cognitive impairment would interfere with his daily functioning and lead to an earlier diagnosis of dementia. Measurements and diagnostic criteria developed in one setting or country may therefore not be entirely appropriate in another; cross-cultural validation is of critical importance as disease concepts and criteria are translated and applied internationally.
RISK AND PROTECTIVE FACTORS AND THE MEANING OF ‘RISK’ Going beyond measures of disease distribution (prevalence and incidence), epidemiology also plays a major role in identifying disease determinants (risk and protective factors). As the term ‘risk’ is most commonly used in epidemiology, it refers to the probability of developing future disease. Thus, ideally, inferences about risk factors should be drawn from prospective studies and not cross-sectional or retrospective studies. Within any population, there are individuals who currently have disease, while the remainder are currently free of disease. A true risk factor is one associated with a significantly higher probability of future disease developing in currently disease-free individuals. The subgroup possessing this risk factor has a higher incidence rate of the disease than the subgroup without that risk factor. Similarly, protective factors are those associated with a lower probability and incidence rate of future disease. It is extremely important to recognize that an identified risk factor may not be the direct cause of the disease. It may be within the causal pathway, or might play a mediating or moderating role between a causal factor and the disease, or may be a surrogate for a causal factor. Further, a risk factor is not necessarily modifiable or preventable. Note that while some studies have singled out risk and protective factors for Alzheimer’s disease, many have examined all dementias together, and, other than their genetics, little is known of risk factors for early-onset dementias. For overall late-onset dementia, which is mostly Alzheimer’s or vascular, the strongest known risk factor is greater age, as demonstrated by incidence rates increasing with age. Based on similar incidence rates in men and women, at least up until age 90, female gender may not be a true risk factor as previously supposed. Several studies have indicated that lesser education increases the risk of dementia; the underlying mechanism is not known. Possibilities include education being a reflection of, or a promoter of, greater cognitive ‘reserve’ capacity that allows the brain to resist or compensate longer for the increasing pathology within it. Alternatively, education could be a surrogate for lifelong socioeconomic status and its consequences, including nutrition and health care; or a confounding variable in the diagnosis of dementia based on cognitive test performance. A positive family history of dementia in a first-degree relative increases the risk of dementia, suggesting a hereditary component. The genetics of AD have been studied the most extensively. While many genes have been reported to play a role in AD, there is, thus far,
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conclusive evidence for only three deterministic genes and one susceptibility gene. Mutations of the APP (amyloid precursor protein) gene on chromosome 21, PS-1 (presenilin 1) gene on chromosome 14, and the PS-2 (presenilin 2) gene on chromosome 1 are all associated with early-onset familial AD. Relevant to the APP gene, Down syndrome, caused by trisomy of chromosome 21, is a well-established risk factor for AD. The one susceptibility gene consistently associated with sporadic cases and late-onset cases is the polymorphic APOE (apolipoprotein E) gene, on chromosome 19, also associated with cholesterol elevation. The E*4 allele of this gene is associated with higher risk and/or earlier onset of Alzheimer’s disease in a dose-related fashion, with homozygosity conferring higher risk than heterozygosity. In epidemiological studies, the APOE*4 genotype is associated with a two- to three-fold elevation of probability of AD. The exceptions are African populations, where the APOE*4 allele is of high frequency but appears not to increase AD risk, and African American populations, where risk elevation is present but lower. This paradox has been attributed to competing risk of vascular disease. Unlike the mutations, the APOE*4 genotype only increases susceptibility and does not guarantee that the disease will occur. A comprehensive review of the genetics of AD and other dementias is beyond the scope of this chapter. There is growing evidence that a host of cardiovascular risk factors, including but not limited to hypertension, hypercholesterolaemia, diabetes mellitus and obesity, all increase the risk of not only overall dementia and vascular dementia but also of AD. One explanation is that these factors operate primarily by causing cerebrovascular disease, which interacts with degenerative pathology, leading to earlier onset of the dementia syndrome. Another is that they directly influence neurodegeneration, for example by influencing the metabolism or accumulation of amyloid protein in the brain. From the epidemiological perspective, the most striking finding from long-term prospective studies is that dementia risk is elevated by hypertension, elevated serum cholesterol and obesity that are present in middle age, but in not old age. In fact, the onset of dementia in later life is preceded by a period of low blood pressure and cholesterol. These findings suggest, first, that the brain pathology that causes dementia develops over many decades and, second, that it is not only the presence or absence of a given factor but the timing and duration of exposure to the factor that influence the risk of dementia. Other reported risk factors from the epidemiological literature are based on less consistent evidence. They include, for example, history of head trauma with loss of consciousness, possibly acting synergistically with the APOE*4 genotype, thyroid abnormalities, and exposure to certain general anaesthetic agents. Potential protective factors include the rare APOE*2 genotype, intake of diets rich in antioxidants, exposure to the lipid-lowering drugs HMG Co-A reductase inhibitors (‘statins’), exposure to nonsteroidal anti-inflammatory drugs (NSAIDs), exposure to oestrogen supplements, physical exercise and cognitive exercise. It is difficult to draw firm conclusions about many of these factors because, although they show negative associations in observational studies, intervention studies using them have not revealed benefits in preventing or delaying the onset of dementia. Some observational data suggest that oestrogen supplements taken for several years, starting at menopause, may reduce incidence of Alzheimer’s disease at least a decade later. However, clinical trials of oestrogen supplements taken
in later life have not shown a protective effect against dementia and in fact suggested an increased risk. As noted earlier, the timing and duration of exposure to risk and protective factors may be critical. Two examples will be discussed to further illustrate the complexity of putative risk relationships. Cigarette smoking has been shown in cross-sectional as well as some prospective epidemiological studies of older adults to be associated with a lower probability of Alzheimer’s dementia. Short-term trials of transdermal nicotine patches have been inconclusive. It is certainly plausible that the nicotine use can have cholinergic effects that promote cognitive performance. However, it is also likely that the apparent protective effect is an artefact reflecting survival bias. Smokers who survive into old age without succumbing to heart and lung disease or cancer might be an unusually hardy group with enhanced capacity to resist many diseases including AD; those who died before they could develop dementia cannot participate in these studies. Depression: in case-control studies, individuals with AD are more likely than healthy controls to have had previous histories of major depression. Older adults with major depression have cognitive deficits which resolve only partially when the depression remits. Major depression in younger adults has been found to be associated with atrophy of the hippocampal cortex, which has been attributed to prolonged hypercortisolaemia caused by depression16 . The hippocampus and medial temporal lobe are the areas typically affected by AD pathology. An autopsy study of patients with AD showed that those who had suffered major depression earlier in life had greater density of degenerative pathology in their hippocampi than those with no previous history of depression17 . However, one prospective population study was able to divide elderly participants without dementia into one subgroup which developed dementia over the next several years and another subgroup that remained dementia free. Depressive symptoms at the beginning of the study did not predict rate of cognitive decline in either group; subsequent cognitive decline was primarily explained by the incipient dementia18 . A potential unifying hypotheses is that depression earlier in life may increase the brain’s vulnerability to dementia, while late-onset depression may be merely an early manifestation of the dementing disorder.
BEHAVIOURAL AND PSYCHOLOGICAL SYMPTOMS OF DEMENTIA Although cognitive impairment is the clinical hallmark of the dementias, Alzheimer’s original case report was based on a woman who was brought for care primarily because of her behavioural and psychological disturbances19 . These are still the symptoms that frequently bring patients with dementia into the mental health care system, but they have not been the focus of much epidemiological work. At least two major population-based studies have shown that the majority of patients with dementia have one or more neuropsychiatric symptoms which add considerably to personal distress and caregiver strain. Irritability and depressed mood are somewhat more common in earlier
DEGENERATIVE AND RELATED DISORDERS and milder stages of disease, while wandering, apathy and delusions are more common in more advanced disease20,21 .
STUDY METHODS For a comprehensive review, readers are directed to any standard epidemiology textbook. A few critical points follow. Different inferences should be drawn from different types of studies: for example, observational vs. experimental; cross-sectional vs. longitudinal; clinical case-control vs. population based. The source of the study sample, its size, and its potential for bias should be taken into account when interpreting the results and generalizing beyond that sample. Statistical significance indicates that the result is unlikely to have occurred by chance, but does not mean that the effect was large in size or that it was clinically significant. Screening tools should be selected after consideration of both sensitivity and specificity, which are usually enhanced at the expense of each other. The same tool, with no change in sensitivity or specificity, can have different predictive value in different populations, depending in part on how prevalent the disease of interest is in a given population. Brain imaging and other biomarker-based approaches to diagnosis are gaining ground in clinical research as well as clinical practice, especially in the more affluent countries. To a lesser extent, epidemiological studies are incorporating these methods to determine their utility and validity for diagnosis at the population level, and to examine the distribution of these markers in individuals outside the specialty clinical setting. Very few epidemiological studies include autopsy data. They have shown the remarkable heterogeneity of neuropathology among individuals with dementia in the community, and also the extent of pathology that exists in relatively old individuals who were cognitively intact until the time of death6 .
FUTURE DIRECTIONS Future research in the epidemiology of dementia faces both opportunities and challenges. The distribution of dementia and milder forms of cognitive impairment must be understood in a variety of populations, some of which have never been studied. As new tests and biomarkers are developed in specialized research settings, their validity must be ascertained in the community before they are recommended for widespread clinical use. Such research will contribute substantially to improved diagnosis and even preclinical detection of disease. Future studies will also focus on normal ageing, establishing norms for a wide range of populations to help distinguish healthy from pathological ageing. Longer-term population studies must track dementia incidence rates over time, to determine whether or not successive generations are following the same trends as life expectancy increases. They must also examine potential relationships of incidence to the different lifetime exposures in different generations. There is a growing call for ‘life-course epidemiology’; that is, studies that start following cohorts of people when they are young or middle aged22 . These studies will minimize survival bias and allow risk and protective factors to be studied early enough, and for long enough, to shed light on their long-term relationship with the dementias of later life. Such data will provide greatly improved information regarding potentially modifiable risk factors, and provide the basis for strategies to prevent dementia, or at least reduce its incidence, in future generations.
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REFERENCES 1. World Health Organization. The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. Geneva: World Health Organization, 1992. 2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision: DSM-IV-TR. Washington DC: American Psychiatric Association, 2000. 3. Kinsella K, Velkoff VA. An Aging World: 2001 , US Census Bureau International Population Reports P95/01-1. Washington, DC: Government Printing Office, 2001. 4. Erkinjunnti T, Ostbye T, Steenhuis R, Hachinski V. The effect of different diagnostic criteria on the prevalence of dementia. N Eng J Med 1997; 337: 1667–74. 5. Rom´an GC, Tatemichi TK, Erkinjuntti T et al. Vascular dementia: diagnostic criteria for research studies. Report of the NINDS-AIREN International Workshop. Neurology 1993; 43: 250–60. 6. Schneider JA, Arvanitakis Z, Bang W, Bennett DA. Mixed brain pathologies account for most dementia cases in communitydwelling older persons. Neurology 2007; 69: 2197–204. 7. Jorm AF, Korten AE, Henderson AS. The prevalence of dementia: a quantitative integration of the literature. Acta Psychiatr Scand 1987; 76: 465–79. 8. Aarsland D, Zaccai J, Brayne C. A systematic review of prevalence studies of dementia in Parkinson’s disease. Move Disord 2005; 20: 1255–63. 9. Gao S, Hendrie HC, Hall KS, Hui S. The relationships between age, sex, and the incidence of dementia and Alzheimer disease: a meta-analysis. Arch Gen Psychiatry 1998; 55: 809–15. 10. Fitzpatrick AL, Kuller LH, Ives DG et al. Incidence and prevalence of dementia in the Cardiovascular Health Study. J Am Geriatr Soc 2004; 52: 195–204. 11. Kalaria RN, Maetre GE, Arizaga R et al. Alzheimer’s disease and vascular dementia in developing countries: prevalence, management, and risk factors. Lancet Neurol 2008; 7: 812–26. 12. Ferri CP, Prince M, Brayne C et al. Global prevalence of dementia: a Delphi consensus study. Lancet 2005; 366(9503): 2112–17. 13. Winblad B, Palmer K, Kivipelto M et al. Mild cognitive impairment – beyond controversies, towards a consensus: report of the International Working Group on Mild Cognitive Impairment. J Intern Med 2004; 256: 240–6. 14. Graham JE, Rockwood K, Beattie BL et al. Prevalence and severity of cognitive impairment with and without dementia in an elderly population. Lancet 1997; 349(9068): 1793–6. 15. Busse A, Bischkopf J, Riedel-Heller SG, Angermeyer MC. Mild cognitive impairment: prevalence and incidence according to different diagnostic criteria. Results of the Leipzig Longitudinal Study of the Aged (LEILA75). Br J Psychiatry 2003; 182: 449–54. 16. Sheline YI, Gado MH, Kraemer HC. Untreated depression and hippocampal volume loss. Am J Psychiatry 2003; 160: 1516–8. 17. Rapp MA, Schnaider-Beeri M, Grossman HT et al. Increased hippocampal plaques and tangles in patients with Alzheimer disease with a lifetime history of major depression. Arch Gen Psychiatry 2006; 63: 161–7.
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18. Ganguli M, Du Y, Dodge HH, Ratcliff GG, Chang CC. Depressive symptoms and cognitive decline in late life: a prospective epidemiologic study. Arch Gen Psychiatry 2006; 14: 419–27. 19. Alzheimer A. Uber eine eigenartige Erkrankung der Hirnrinde. Allg Z Psychiatr 1907; 64: 146–8. 20. Savva GM, Zaccai J, Matthews FE et al. Prevalence, correlates, and course of behavioural and psychological symptoms of dementia in the population. Br J Psychiatry 2009; 194: 212–19.
21. Lyketsos CG, Sheppard J-E, Steinberg M et al. Neuropsychiatric disturbance in Alzheimer’s disease clusters into three groups: the Cache County study. Int J Geriatr Psychiatry 2001; 16: 1043–53. 22. Ben-Shlomo Y, Kuh D. A life course approach to chronic disease epidemiology: Conceptual models, empirical challenges, and interdisciplinary perspectives. Int. J. Epidemiol 2002; 31: 285–93.
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An Introduction to the Medical Research Council Cognitive Function and Ageing Studies (CFAS) I and II Fiona E. Matthews1 and Carol Brayne2 1 MRC 2 University
Biostatistics Unit, Institute of Public Health, Cambridge, UK of Cambridge, Department Public Health and Primary Care, Cambridge, UK
INTRODUCTION The rise in numbers of older people and the changing proportion of old to young people has been predicted for some time. It has become clear that the potential impact of this ageing phenomenon would have a major impact on population health profiles. Its potential impact on social and economic aspects of the more affluent countries highlights ageing as a sufficiently important issue in resource allocation. Discussion between the UK Department of Health, UK Medical Research Council (MRC), and experts from the scientific and medical communities late last century resulted in the decision that brain changes, most particularly cognitive decline, dementia and their relation to disability were key topics requiring investigation at the population level. This prompted a decision to invest in research into this area and a working group was convened, which included those with epidemiological and biostatistical expertise relevant to such investigation. Out of this working group a successful bid for the study now known as the MRC Cognitive Function and Ageing Study (CFAS) emerged1 .
In 2008 additional funding from the MRC enabled the introduction of a new cohort in three of the original CFAS centres (Cambridgeshire, Newcastle and Nottingham). Further funding from the Economic & Social Research Council (ESRC) in 2009 will enable a new cohort to be recruited to the Gwynedd centre (plus a new centre in Neath, Port Talbot) which focuses more on the social aspects of ageing.
THE AIMS OF THE STUDY The aims of the study (see Box 39.1) have evolved over its existence and cover a wide range including descriptive epidemiology, neuropathology, policy, molecular epidemiology and ethics. The principal neuropathological aim was to determine the contribution of different underlying pathologies to the rates of dementia and the geographical variation in these rates, and to the burden of disability.
Box 39.1 CFAS core aims STUDY DESIGN The study is a six-centre multidisciplinary multiphased longitudinal design. There are five identical sites and one with a different sampling and interview structure. This centre (Liverpool, also known as the ALPHA study, see Figure 39.1) was already funded at the time of the discussions noted above and thus started earlier than the other five centres2 . The other five centres (Cambridgeshire, Gwynedd, Newcastle, Nottingham and Oxford) were able to follow a standardized design and are referred to as the five identical sites. Their basic structure was a two-phase design with a screening interview followed by an assessment interview shortly afterwards, with a repeat at two years. The fieldwork began in 1991 to 1993 (centre dependent)3 (see Figure 39.2 for flow diagram). Additional features are more fully described on the website (www.cfas.ac.uk).
CFAS I core aims: The main descriptive epidemiological aims include:
• the estimation of the prevalence and incidence of cognitive •
•
decline and dementia, and geographical variation in those rates; the determination of the natural history of dementia, in particular the rate of progression of cognitive decline including the distribution of the interval between the identification of cognitive impairment and death; the identification of factors associated with differing rates of cognitive decline and with the risk of dementia.
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• to compare the size of relationship of known genetic fac-
Additional aims included:
• to determine the prevalence and severity of pathological • •
•
• • •
•
•
lesions in the brain of an unselected cohort of older people with and without cognitive impairment; to determine the frequency of specific pathological diagnoses in people with cognitive impairment; to correlate severity of specific pathologies with patterns of cognition, function and behaviour in life independently of clinical and pathological diagnostic categories. CFAS II core aims include: to update profiles of cognitive and physical function, physical and mental health and disability of people aged 65 or over in four of the original CFAS centres: Cambridgeshire, Gwynedd, Newcastle and Nottingham; to estimate the cohort change in prevalence and incidence of cognitive impairment and dementia; to investigate whether the measures that characterize the intermediate stage (mild cognitive impairment) best within the original CFAS are stable across generations; to quantify medication, health, social service use, social support, residential characteristics and care states, including formal and informal care, of people with dementia, frailty or physical disability across the three sites; to assess the contribution of different diseases, particularly dementia, to any change in the burden of disability over time, specifically whether diseases have become more or less disabling and estimate the effect of prevention vs. treatment;
The DNA resource was incorporated in a later phase of CFAS I. In CFAS II saliva is collected at baseline. The main molecular epidemiological aim has been to support genetics studies that have sought genes associated with dementia, Alzheimer’s disease, mixed and vascular dementia, cognitive impairment and decline. A later aim of the study was to explore the ethical and legal aspects of brain donation within a population-based sample given changing perception surrounding organ donation. The study also aimed to act as a core resource and provide a framework to support specific sub-studies in lone or joint centres. The Resource Implication Study 4 – 10 used this framework to achieve the core policy aim (see above).
METHODOLOGY Because the main study is focused on cognition and dementia it has collected the necessary dimensions of physical and mental health to arrive at a study diagnosis of dementia. It now has four major themes: (i) dementia (covering all aspects including cognition); (ii) depression; (iii) disability and healthy life expectancy; and (iv) health policy and health. In addition it has particular strengths in that it is one of
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tors with frailty, including cognitive impairment, with those found in the earlier cohort; to provide a foundation for other collaborative studies that investigates biomarkers and further investigation of early markers, including imaging, for risk of cognitive decline.
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1999
2002
32
11
W5
W6
453 322
W1P1
W1P2
W2P1
W2P2
W3P1
W3P2
W4
Figure 39.1 MRC Alpha Study: Liverpool centre design number of interviews Source: Morris, J.C. (1993) The Clinical Dementia Rating (CDR): current version and scoring rules. Neurology, 43, 2412–4
DEGENERATIVE AND RELATED DISORDERS
215 1991
(S0) PREVALENCE SCREEN N = 13004 ( 7322 Deaths to 31/12/2002)
(A0) PREVALENCE ASSESSMENT N = 2640
1992
(F1) ANNUAL FOLLOW UP N = 920 1993 (C2) COMBINED SCREEN AND ASSESSMENT N = 1651
(S2) INCIDENCE SCREEN N = 7176
(A2) INCIDENCE ASSESSMENT N = 1463
(F3) ANNUAL FOLLOW UP N = 590
1994
1995
1996
(C6) COMBINED SCREEN AND ASSESSMENT N = 2052
1997
1998
(C8) COMBINED SCREEN AND ASSESSMENT N = 390
1999
2000
(C10) COMBINED SCREEN AND ASSESSMENT
2001
N = 3145
Figure 39.2 CFAS I identical centres study design the very few truly population-based programmes with a brain donation programme – individuals in the study have indicated whether they wish to contribute to brain research through the donation of their brain after death (declaration of intention to donate).
Study Population The first aim of the study was to estimate age-specific rates of prevalence of cognitive impairment and dementia among those aged 65
and over. The population is thus all those aged 65 years and over on the index date for centre (1990, 1991), living within a specified geographical location. Background information on the demographics of the populations sampled was collected from the Office of Population Censuses and Surveys (OPCS) 1990–91 census, now Office for National Statistics (ONS), to relate to regional and national data. Family Health Services Authority (FHSA) lists were used as the sampling frame. The frame would be incomplete if eligible members of the population were not registered with a GP. However, individuals
216
PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRY
in long-stay hospitals remain registered with their GP two years after institutionalization so sampling from FHSA lists ensured their inclusion. Each centre looked into the practices of long-stay hospitals in their area to confirm this. The FHSA list of individuals was used for sampling on a geographical basis. Each centre defined this area, and the study population was drawn from all those who were resident within it. Problems of inaccuracy, patients who died or moved away but were still on the FHSA list, were resolved by asking GP surgeries to check the lists. On this basis, a sample of sufficient size to yield 2500 interviews of individuals aged 65 years and over, stratified by age (equal numbers aged 65–74 and 75 plus) was chosen from the FHSA lists for each selected area (in Liverpool this was 5000 interviews stratified by sex and five-year age band). The population is flagged at ONS for mortality and the database is updated continuously. The follow-up has been determined by funding and the design of associated bolt-on studies. The main follow-up waves for the identical sites are captured in the audit trail shown in Figure 39.2, which shows the numbers for the main screen, assessment, one-year follow-up and two-year rescreen, new selection for assessment and further one-year followup, six-year follow-up of the assessed (with venepuncture), eight-year follow-up of those with intentions to donate, and 10-year follow-up of the total sample. In addition to this the main associated studies are the Resource Implications Study (four centres – Cambridgeshire, Newcastle, Nottingham, Oxford), which followed those who provided care to the physically and cognitively frail at baseline4 – 10 , the ESRC-funded Healthy Ageing Project, which interviewed in detail those who were not selected into the Resource Implications Study in Nottingham and Cambridgeshire11 – 16 , the Network Study conducted in Gwynedd and Liverpool to examine individuals’ social networks, an embedded case-control study at two-year incidence stage (Cambridgeshire), and the ongoing brain donation programme in all centres. This programme, in combination with the bloods taken at year 6, form the major components of the biological resource of the study. CFAS II will also have the same sampling frame and study size (at each centre). CFAS II is longitudinal at outset with two complete sweeps of the data planned. Each phase is two years apart.
Interview Method All interviews were conducted in the respondent’s place of residence, using portable computers with customized software. If the interviewer felt that the respondent was frail and tiring, or becoming agitated, the short ‘priority mode’ set of questions could be invoked manually. Permission was also sought to access GP and hospital notes.
Content CFAS I screening interview contains questions on residence, marital status, education and occupation, living circumstances, contact with friends and family, health and social care contact, self-reported physical health, instrumental activities of daily living and activities of daily living, cognitive measures (Mini Mental State Examination (MMSE) with augmentation) and medication. The assessment interview is mainly the Geriatric Mental State Examination (GMS) adapted for CFAS17 – 19 . This is a structured psychiatric interview, which collects sufficient information for algorithmic ‘diagnosis’ in
the major psychiatric disorders of old age (dementia, depression, anxiety and psychosis). This has been validated against clinical diagnosis and the instrument has been widely used in Europe and now forms part of the 10/66 international instrument. This interview has been augmented with questions from the CAMDEX (Cambridge Examination for Mental Disorders of the Elderly) including CAMCOG20 , the longer neuropsychological assessment. The relative or carer interview is mainly the History and Aetiology Schedule, the informant interview that accompanies the GMS. The combined screen and assessment interview merges the two interviews but compresses some aspects of data collection. Complete versions of all the interviews including the interview questions and responses are available on the website. CFAS II interview contains all the previous screening and assessment interview information plus additional questions on diet, social activity and objective measures of hearing and physical activity. The neuropathological assessment follows the standardized protocol of the Consortium to Establish a Registry for Alzheimer’s Disease (CERAD)21 , with the exception that the neuropathologist is blind to the interview data. This covers in a semiquantitative form the main areas required for the assessment of neurodegenerative and cerebrovascular disorders. The forms are available on the website. The main genetic analyses have been on ApoE and ACE. CFAS II has saliva collection at the outset for genetic comparisons. Data collection in Liverpool was broadly similar to the other five sites except that the screening interview consisted of the GMS plus some of the screening interview questions listed above.
Selected Study Findings The study has reported on prevalence, incidence (see Figure 39.3) and risk factors of dementia (Table 39.1), and lack of variation in these across the five identical sites22 – 24 . It has provided profiles of cognition for MMSE, extended MMSE and CAMCOG, weighted back to the population25,26 . It has reported on risk for incident dementia including ApoE and ACE (Table 39.2)27 – 29 . It has examined the relationship of cognition to mortality30 . In addition, the study has reported on a variety of impairments to healthy life in old age and their population burden31 – 42 and on a variety of neuropathological markers related to dementia and old age (see Table 39.3)43 – 54 . Recent publications have also included the investigation of behavioural (BSPD) symptoms of dementia and on stability and population applicability of mild cognitive impairment55 – 59 . The Resource Implications Study has provided data for examination of carer burden and the costs of care for the physically and cognitively frail6,10 . The data have been used for projection forward for these vulnerable groups and also for the costs of long-term care60 . Liverpool has published on the prevalence of dementia, depression and neurosis, together with incidence of dementia and schizophrenia2,61 – 66 .
CFAS I AND II AS A RESOURCE The study is multisite and multidisciplinary. The population is truly representative with high response rates at each stage over diverse sites. Where there is no heterogeneity across sites the study is sufficiently large to provide indicative values for national estimates. The broad scope of measures has allowed the study to contribute to ageing research across a wide range of topics. There are repeat
DEGENERATIVE AND RELATED DISORDERS
217
90 Men 80
Women
Incidence per 1000 Person-years
70 60 50 40 30 20 10 0 65–69
70–74
75–79
80–84
85+
Age group (years)
Figure 39.3 Incidence of dementia by sex (five identical centres) Source: adapted from Matthews71
Table 39.1 Risk factors for incident dementia (sociodemographic)
Age (90+ years vs. 65+ years) Sex (women vs. men) Education (<9 vs. 10+) Self-reported health (poor vs. good) Stroke (yes vs. no) Parkinson’s disease (Yes vs. No) General anaesthesia (Yes vs. No)
OR∗
(95% CI)
25.6 1.6 1.9 3.9 2.1 3.5 0.6
(11.6–56.9) (1.1–2.4) (1.3–2.2) (2.2–6.4) (1.1–4.2) (1.3–9.3) (0.4–0.9)
∗ Adjusted for all other factors in the table.
Source: Morris, J.C. (1993) The Clinical Dementia Rating (CDR): current version and scoring rules. Neurology, 43, 2412– 4
measures on cognition and function, which allows examination of trajectories. There are only two other population-based studies with brain donation in Europe67 . The study weighted the sample towards the over 75 age group at baseline, which has provided more robust data for the oldest old. As in all epidemiological research in older populations it would be desirable to have higher response and lower dropout between waves, but analysis can adjust for loss between interviews68 – 70 . Blood taking and clinical assessment (including imaging) at baseline was not possible because of funding constraints, but venepuncture was included at year 6. The risk measures are self-report, using the available validated measures of the era. The study actively encourages collaboration, and there are established mechanisms for approaching us via the themes mentioned above. Information is available on the website and also through contact with theme leads.
Table 39.2 Incidence of dementia and ApoE genotype Comparison using non-demented controls Adjusted*
Allele ε2 ε3 ε4 Genotype ε2/ε2 ε2/ε3 ε2/ε4 ε3/ε3 ε3/ε4 ε4ε4
Adjusted* and weighted**
OR
95% CI
OR
0.6 1.0 2.2
0.3–0.9
0.3 1.0 2.9
0.1–0.6
0.5 0.6 0.6 1.0 2.3 5.0
0.0–5.7 0.3–1.1 0.2–2.3
0.3 0.2 0.2 1.0 3.6 7.9
0.1–1.7 0.1–0.7 0.0–1.3
1.6–3.0
1.5–3.6 1.9–13.0
95% CI
1.7–4.9
1.8–7.3 1.6–39.2
∗ For age group, sex, education and social class. ∗∗ For study design and dropout.
Source: reproduced from Keage29
The study website, www.cfas.ac.uk, configures information under themes, documentation, publications and data. There is also a list of study contacts.
CONCLUSION The methods and results of the Medical Research Council Cognitive Function and Ageing Studies (MRC CFAS) I and II are described
218
PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRY
Table 39.3 Neuropathological factors associated with dementia Neuropathological findings Age at death <80 years 80–89 years ≥ 90 years Brain weight for sex Low Average High Neuritic plaques in neocortex None Mild Moderate Severe NFT in neocortex None Mild Moderate Severe Congophilic angiopathy None Mild Moderate Severe Lewy bodies No Yes Overall vascular pathology None Infarcts/haemorrhage SVD/WML/lacunes Both Hippocampal atrophy None Mild Moderate Severe
Age-adjusted analysis OR (95% CI) 1.0 3.2 5.2 5.7 2.0 1.0 1.0 1.2 2.9 18.5
(1.8–5.5) (2.9–9.4)
Multivariable analysis OR (95% CI)
PAR %
(95% CI)
<.001
1.0 2.5 3.4
(1.1–5.8) (1.4–8.3)
8 10
(0–16) (3–16)
(1.9–9.2) (1.0–4.2)
12 5
(5–19) (0–11)
<.001
4.1 2.1 1.0
(2.1–43)
8
(3–14)
(3.2–10) (1.2–34) (0.7–2.2) (1.7–5.0) (7.3–47)
1.0 1.3 8.9 ∞
(0.8–2.1) (4.0–20)
1.0 1.9 4.0 ∞
(1.1–3.3) (2.2–7.4)
1.0 3.2
p
1.0 <.001
9.7
1.0 1.0 7.1
(0.5–1.80) (2.3–22)
11
(5–19)
1.0 1.8 2.9
(0.8–3.8) (1.2–6.8)
2 5
(0–6) (1–10)
0.003
1.0 3.5
(1.3–9.3)
3
(1–7)
0.003
1.0 2.4 3.7 4.8
(0.4–12) (1.5–9.6) (1.9–12)
12 9
(3–19) (3–15)
(0.9–3.7) (1.5–7.5)
2 8
(0–6) (2–15)
<.001
<.001
(1.5–6.9)
1.0 1.0 2.5 2.9
(0.3–3.8) (1.4–4.4) (1.6–5.5)
1.0 2.2 6.9 11.1
(1.3–3.9) (3.7–13) (2.5–50)
1.0 1.8 3.4
<.001
Source: adapted from MRC CFAS Neuropathology Group54
above, as well as the design and aims of these two studies (started in October 2008). CFAS I and CFAS II are population-based studies of individuals aged 65 and above living in England and Wales. CFAS I has produced a range of results and a selection are shown within the chapter. The study data are part of a facilitated managed resource for collaborations, details of which have been described.
ACKNOWLEDGEMENTS We are grateful to our respondents, their families and their primary care teams. The study has only been possible because of the dedication of a large number of individuals over the years, who are listed on the website. The MRC CFA study has been supported by major awards from the Medical Research Council and the Department of Health. Thanks are also due to the Biological Resource Advisory Group for overseeing this aspect of study.
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The Lundby Study Mats Bogren, Cecilia Mattisson and Per Nettelbladt Department of Clinical Sciences, Psychiatry, Lund University Hospital, Sweden
From the Lundby Study, reports on dementias in the elderly for the period 1947–72 have been published. In the EURODERM comparative prevalence studies1,2 , the Lundby prevalence rates of senile dementia of the Alzheimer type (SDAT) in the age intervals 60–69, 70–79 and 80–89 were 0.3%, 2.5% and 10.9%, respectively, and for vascular dementia 0.8%, 3.5% and 6.3%. In another study3,4 , the cumulative lifetime probability of contracting SDAT was reported to be 25.5% in men and 31.9% in women. For severely impaired cases, the figures were 15.5% and 22.2%, respectively. For vascular dementia the figures were 29.8% in men and 25.1% in women, for severe cases 16.6% and 15.2%, respectively. Background factors to SDAT and vascular dementia have also been studied5,6 . The last follow-up in 1997 covering the period 1972–97 has now enabled us to compare the population’s first incidence of dementia and other organic brain disorders over the two time periods 1947–72 and 1972–977 . The Lundby study is a longitudinal investigation of mental disorders in a total population. It originally included all people living in a rural area in 1947 or 19578,9 . This population has been investigated in 1947, 1957, 1972 and 19978 – 11 and at each point information has been obtained about the development of the mental and physical health for all individuals alive at the previous investigation providing an opportunity to observe changes of mental disorders in the population over 50 years. At the inception, the study population lived in two parishes outside the university town Lund in the southern part of Sweden. In 1947 the Lundby area was rural with 2550 inhabitants, aged 0–92 years. In 1957 1013 newcomers were included (one-third born since 1947; and two-thirds immigrated). In all follow-ups, those subjects who had moved out of the area were also investigated. Information was also collected about those who were deceased since the previous followup. The present findings apply to the total cohort (n = 3563, male 1823, female 1740). By 1972 gradual urbanization had changed the Lundby area from a farming district into a suburban area4 , which was even more obvious in 1997. Moreover, in 1972, many subjects had moved away from the Lundby area; of the 2827 still alive in 1972, 1424 remained, while 1403 had moved; in 1997, 602 of the 1797 survivors remained, while 1195 had moved. At the follow-ups the aim has been to obtain as much information as possible about all episodes of mental and somatic disorders in
all individuals in the population. Data was gathered from several sources: interviews, case registers, case notes, autopsy reports and key informants11 – 14 . Thanks to the many data sources the diagnostic attrition 1947–72 was only 1%; although it was 6% between 1972–97. However, in those over 50 years old in 1972 the attrition 1972–97 was 2% in males and 3% in females. Psychiatrists have conducted all interviews and evaluations of data. The diagnostic principles have been kept similar and were based on consensus9 – 11 . The diagnoses were aimed at getting ‘a rough picture of the relative distribution of the main types of mental illness in the population’9 . Neurotic and psychotic disorders were disorders without evidence of organic aetiopathology. Neurotic, as opposed to psychotic, indicated preserved insight. Organic brain disorders included states with global cognitive dysfunction or gross personality or behavioural disturbance, with obvious organic causation. Only one diagnosis per episode of disorder was recorded with organic brain disorders ranking higher than psychotic disorders, which in turn takes precedence over neurotic disorders. Furthermore, every episode of disorder was rated along with the degree of dysfunction caused by it (minimal, mild, medium, severe or very severe) according to the criteria defined by Leighton et al.15 . A mild degree of impairment corresponds to a Global Assessment of Functioning (GAF) score of 70–61; medium corresponds to 60–51, and severe to 50–31. Episodes with medium, severe or very severe impairment16 were chosen to indicate caseness. For all episodes, onset and termination were assessed as closely as possible using all sources of information. Incidence rates for organic brain disorders in the periods 1947–72 and 1972–97 were obtained as the number of first occurrences of the outcome divided by the total number of person-years under risk for the outcome in individuals who had previously been free from the outcome. Individuals contributed with risk-years until contracting the outcome, dying, dropping out of the study or the end of the study period. When age- and sex-specific incidences of organic brain disorders in 1947–72 and 1972–97 were compared, the rates had decreased consistently from the first to the last period in all age intervals but 40–49 (Table 40.1). Both male and female age-standardized firstincidence rates decreased significantly from the first to the last period.
Principles and Practice of Geriatric Psychiatry, 3rd edn. Edited by Mohammed T. Abou-Saleh, Cornelius Katona and Anand Kumar 2011 John Wiley & Sons, Ltd
DEGENERATIVE AND RELATED DISORDERS In both periods the age-standardized incidence rate of organic brain disorders was higher in males than females. The difference was significant in 1947–72, but not in 1972–97. When the impairment threshold to indicate caseness was changed from medium to severe, the age-standardized first incidence per 1000 years at risk of organic brain disorders declined from 3.4 to 2.0 in males and from 2.9 to 2.0 in females from 1947–72 to 1972–97. There were no cases of organic brain disorder with impairment level under medium. In the period 1947–72 dementia constituted 80% and milder organic brain disorders 20% of the category organic brain disorders. In the period 1972–97 the corresponding figures were fairly similar at 83% and 17%, respectively. When organic brain disorder was divided into dementia and other organic brain disorders not reaching the dementia threshold, one
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could still, for both groups, see a decrease of the age-standardized first incidences from the first to the second 25-year investigation period. In males the age-standardized first incidence of dementia fell from 5.1 to 2.1 per 1000 years at risk and in females from 4.0 to 2.1. The age-standardized first incidence of organic brain disorders not reaching the dementia threshold fell from 1.2 to 0.6 in males. Among females there was only a marginal decrease from 0.5 to 0.3. The age interval responsible for the reduction of the agestandardized first incidence of dementia was above all the 70–99 interval, while the age intervals concerned regarding the reduction of milder organic brain disorders were those under 70. In males aged 70–99 the first incidence of dementia decreased from 28.4 to 10.9 per 1000 years at risk. In females the first incidence decreased from 23.4 to 12.6.
20
Incidence rate per 1000 years at risk
18 Dementia Men
16
Other Organic Brain Disorder Men
14 12 10 8 6 4 2 0
20
Incidence rate per 1000 years at risk
18 Dementia Women
Other Organic Brain Disorder Women
16 14 12 10 8 6 4 2 0 47–52
52–57
57–62
62–67
67–72
72–77
77–82
82–87
87–92
92–97
Figure 40.1 Age-standardized first-incidence of dementia and other organic brain disorders of medium + (GAF 60-1) impairment by fiveyear periods 1947–97 Source: Reproduced with permission from Australian & New Zealand Journal of Psychiatry, 2007; 41(2):178–186
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PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRY Table 40.1 Organic brain disorders of medium + (GAF 60-1) impairment. First incidence per 1000 years at risk (µ) with 95% confidence intervals (CI) 1947–72 Age
C
L
Men 15–29 30–39 40–49 50–59 60–69 70–99 Total
3 4 1 12 24 84 128
8354 5669 5683 4997 3495 2676 30874
Women 15–29 30–39 40–49 50–59 60–69 70–99 Total
1 4 0 5 11 73 94
8125 5147 4974 4699 3671 2938 29554
1972–97 µ
95% CI
µ
C
L
95% CI
0.4 −0.0–0.8 0.7 0.0–1.4 0.2 −0.2–0.5 2.4 1.0–3.8 6.9 4.1–9.6 31.4 24.7–38.1 4.2 3.4–4.9 6.4∗ 5.3–7.5
0 2 3 3 15 60 83
1869 3862 5399 5516 4984 4445 26076
0 0.5 −0.2–1.2 0.6 −0.1–1.2 0.5 −0.1–1.2 3.0 1.5–4.5 13.5 10.1–16.9 3.2 2.5–3.9 2.8∗ 2.2–3.4
0.1 −0.1–0.4 0.8 0.0–1.5 0 1.1 0.1–2.0 3.0 1.2–4.8 24.8 19.2–30.5 3.2 2.5–3.8 4.5∗ 3.6–5.4
0 0 1 1 7 80 89
1755 3872 5410 5145 4729 5593 26505
0 0 0.2 −0.2–0.6 0.2 −0.2–0.6 1.5 0.4–2.6 14.3 11.2–17.4 3.4 2.7–4.1 2.4∗ 1.9–3.0
C = First-incident cases. L = Years at risk. ∗ = Age standardized. Source: Reproduced with permission from Australian & New Zealand Journal of Psychiatry, 2007; 41(2):178– 186
Male and female age-standardized first-incidence rates of dementia and other organic brain disorders every fifth year from 1947–97 are seen in Figure 40.1. In both males and females a trend of decreasing incidences of dementia can be observed from 1947–97, while five-year incidences of other organic brain disorders remained fairly constant through the whole period. There are a limited number of studies that have tried to ascertain secular trends of dementia incidence. However, in a study from Rochester, Minnesota, no significant change of the incidence of dementia was seen from 1960 to 198417,18 . One difference from the Lundby study was the shorter length of the observation period. A long period of study might be needed to be able to see a slow change over many years18 . The Lundby population offers an opportunity to study the rates of dementia and other organic brain disorders during a period of great transition in society and development of public health. This transition includes changes of lifestyle (e.g. food, smoking) and increased availability of medical care (e.g. antihypertensive and antidiabetic treatment) as well as changes in the physical environment. Thus, the decrease of organic brain disorders in both male and female subjects may be the result of a healthier lifestyle and availability of treatments protecting against the development of organic brain lesions.
REFERENCES 1. Rocca WA, Hofman A, Brayne C et al. Frequency and distribution of Alzheimer’s disease in Europe. A collaborative study of 1980–1990 prevalence findings. Ann Neurol 1991; 30(3): 381–90. 2. Rocca WA, Hofman A, Brayne C et al. The prevalence of vascular dementia in Europe. Facts and fragments from 1980–1990 studies. Ann Neurol 1991; 30(6): 817–24.
3. Hagnell O, Lanke J, Rorsman B et al. Current trends in the incidence of senile and multi-infarct dementia. A prospective study of a total population followed over 25 years; the Lundby Study. Arch Psychiat Nervenkr 1983; 233: 423–38. ¨ 4. Hagnell O, Lanke J, Rorsman B, Ohman R. The diminishing incidence of chronic organic brain syndromes among the elderly. In Book of Proceedings from the Third European Symposium on Social Psychiatry in Hanasaari, Finland, 1983, 253–61. 5. Hagnell O, Franck A, Gr¨asbeck A et al. Senile dementia of the Alzheimer type in the Lundby Study. An attempt to identify possible risk factors. Eur Arch Psychiat Clin Neurosci 1992; 241: 231–5. 6. Hagnell O, Franck A, Gr¨asbeck A et al. Vascular dementia in the Lundby Study. An attempt to identify possible risk factors. Neuropsychobiology 1993; 27: 210–16. 7. Bogren M, Mattisson C, Horstmann V, Bhugra D, MunkJørgensen P, Nettelbladt P. Lundby revisited: first incidence of mental disorders 1947–1997. Aust NZ J Psychiatry 2007; 41: 178–86. 8. Essen-M¨oller E, Larsson H, Uddenberg C-E, White G. Individual Traits and Morbidity in a Swedish Rural Population. Copenhagen: Ejnar Munksgaard, 1956. 9. Hagnell O. A Prospective Study of the Incidence of Mental Disorder. Lund: Svenska Bokf¨orlaget, 1966. ¨ 10. Hagnell O, Essen-M¨oller E, Lanke J, Ojesj¨ o L, Rorsman B. The Incidence of Mental Illness over a Quarter of a Century. Stockholm: Almqvist & Wiksell, 1990. ¨ 11. Nettelbladt P, Bogren M, Mattisson C, Ojesj¨ o L, Hagnell O, Hofvendahl E et al. Does it make sense to do repeated surveys? – the Lundby Study, 1947–1997. Acta Psychiatr Scand 2005; 111: 444–52. 12. National Board of Health and Welfare (2004). Patient Register. Stockholm, 2004.
DEGENERATIVE AND RELATED DISORDERS 13. National Board of Health and Welfare. The Cause of Death Register. Stockholm, 2004. 14. Community Medicine Institution, Lund University. The DalbyTierp Register. Lund, 2004. 15. Leighton DC, Harding DC, Macklin DB, Macmillan AM, Leighton AH. The Character of Danger. The Stirling County Study, Vol III . New York: Basic Books, 1963. 16. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th edn (DSM-IV). Washington, DC: American Psychiatric Association, 1994.
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17. Kokmen E, Chandra V, Schoenberg BS. Trends in incidence of dementing illness in Rochester, Minnesota, in three quinquennial periods, 1960–1974. Neurology 1988; 38: 975–80. 18. Rocca WA, Cha RH, Waring SC, Kokmen E. A Reanalysis of Data from Rochester, Minnesota, 1975–1984. Am J Epidemiol 1998; 148: 51–62.
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Clinical Features of Alzheimer’s Disease: Cognitive and Non-cognitive Oludamilola Salami and Constantine G. Lyketsos Johns Hopkins School of Medicine and Johns Hopkins Bayview, Baltimore, USA
Alzheimer’s disease is best described as a neurodegenerative brain disease that causes a clinical dementia syndrome. It is the most common neurodegenerative disorder, accounting for over 60% of dementia cases in late life. Alzheimer’s dementia is estimated to affect over 4 million Americans and 21 million persons worldwide1 . The dementia associated with Alzheimer’s disease is heterogeneous and diverse. Symptoms and signs vary with the progression and severity of the illness. Progressive cognitive decline with impaired ability to function in the person’s usual environment is regarded as the hallmark of the clinical syndrome. Memory is invariably affected. There is also dysfunction in other domains of cognition including language, visuo-spatial, perception, recognition, praxis and executive function. Non-cognitive neuropsychiatric symptoms (NPS) are universal over the course of illness and are themselves diverse. These include affective, perceptual, behavioural, motivational and personality changes. Alzheimer’s disease is usually indolent in its early course. Progression of the disease is associated with loss of independent function. The impact on sufferers, caregivers and other loved ones is often profound. Estimates of life expectancy in Alzheimer’s disease range from 3 to 9 years2 . The mortality rate associated with Alzheimer’s dementia is on the order of 10.6 deaths per 100 000 person-years in the population3. Alzheimer’s disease and delirium are clinical syndromes with similarities in clinical features and may be co-morbid. In the early stages of Alzheimer’s disease, the key differences are the acute onset, fluctuating symptoms and the prominent sleep–wake cycle fragmentation which are seen in delirium and not in Alzheimer’s disease. However, advanced Alzheimer’s disease is difficult to differentiate from delirium, except by the clinical history4 . This section focuses on the clinical presentation of Alzheimer’s disease, and the occurrence of its clinical features along a spectrum from early disease to the advanced stages.
COGNITIVE SYMPTOMS Impairment in cognitive function is the core feature of Alzheimer’s disease. Several areas of cognition may be affected and the degree of impairment varies with illness severity (Table 41.1).
Memory Disturbance of memory is regarded as the hallmark of Alzheimer’s disease. Memory impairment is, however, not always the initial symptom. Affective symptoms may often precede memory disturbance5 . It is important to note that the spouse or close relatives of most patients with Alzheimer’s disease are usually the ones who bring the memory deficits to clinical attention, not the patients themselves. Early memory symptoms heralding the onset of dementia include difficulty with the registration and retention of new information, leading to repeating questions or comments. There may also be difficulty manipulating stored information associated with working memory. Delayed spontaneous recall of recently acquired information is impaired in early stages6 . Immediate recall, recognition and registration of information become increasingly affected with progression of illness. As these symptoms worsen, memory dysfunction affects daily function, which is important in differentiating dementia from memory decline associated with normal ageing. Individuals with early Alzheimer’s disease may develop difficulty recalling recent tasks, events, directions and appointments. Those with advanced education or high intellectual reserve may be able to adapt for some time with minimal impact on their daily function. Some resort to memory cues, such as taking notes or keeping journals, to compensate for decline in memory. In moderate to severe stages, long-term memory becomes impaired. There may be inability to accurately recall details of familiar historic events and personal information, including names of family members, birthdays, special occasions or other aspects of declarative memory.
Language Both oral and written impairments of language are found in Alzheimer’s disease. In the early stages, fluent dysphasia may predominate, often in a pattern similar to transcortical sensory aphasia. Characteristic deficits at this stage include diminished vocabulary and word finding difficulty. Individuals with early dementia often have difficulty selecting words and may lose track during conversations6 . Word repertoire shrinks and use of language
Principles and Practice of Geriatric Psychiatry, 3rd edn. Edited by Mohammed T. Abou-Saleh, Cornelius Katona and Anand Kumar 2011 John Wiley & Sons, Ltd
DEGENERATIVE AND RELATED DISORDERS Table 41.1 Cognitive symptoms associated with Alzheimer’s dementia Memory (working, declarative and procedural impairment) Language (aphasia, alexia, agraphia, aprosodia, acalculia) Visuo-spatial dysfunction, recognition impairment or agnosis Execution of previously learned movements or praxis Executive dysfunction (planning, sequencing, abstraction, set shifting, organizing)
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exhibit motor perseveration and poor limb positioning. Ideational apraxia is the inability to perform an action comprised of several steps. An example is pantomiming the act of getting dressed or changing the batteries in a remote control. Given the profound limitations to daily function from apraxia, these symptoms can be very distressing to both patients and care providers. There may also be difficulty recalling the ability to perform previously learned tasks such as driving, using utensils, toileting and self-care.
Executive Dysfunction becomes more simplistic, often described as circumlocutory. There may be paraphasic errors with incorrect word substitutions. In advanced disease, impaired comprehension and word finding difficulties are more pronounced. The ability to communicate effectively becomes impaired. The patient’s speech may become nonfluent with mainly short simple phrases or words. Echolalia and palilalia may also occur as affected individuals develop complete loss of verbal expression. These deficits may extend to reading and writing ability. Some affected individuals may retain their ability to understand and respond to non-verbal and emotional cues.
Visuo-spatial Function Visuo-spatial cognitive impairment and non-verbal visuo-spatial information processing are the characteristic visuo-spatial disturbances observed in Alzheimer’s disease. Visual discrimination, visual recognition and visuo-spatial attention deficits may also occur, but less frequently. Although subtle impairments may be seen with early Alzheimer’s disease, deficits occur more commonly in moderate to severe stages of dementia and often become progressive. There may be impairment in ability to synthesize, integrate and organize visual sensory stimuli or other environmental information. There may also be difficulty developing strategies for complex construction. Some persons with Alzheimer’s disease have impaired right–left orientation and defective re-visualization, which involves internally re-visualizing and imagining a named object and then describing it accurately when prompted. Some may have difficulty with the synthesis of parts of an object into a whole and then properly identifying the whole (classic agnosia). Patients may also have difficulty copying or drawing objects and, with further progression of the illness, lose the ability to construct complex figures or diagrams. Rarely patients present with reduplicative paramnesia, involving the belief that they are in two or more locations simultaneously. Reduplicative paramnesia, more often seen following head injury, can also be regarded as a misidentification syndrome.
Praxis Impairments with planned motor movements are closely related to executive dysfunction. These deficits are usually seen in advanced stages of Alzheimer’s disease dementia. Ideomotor and ideational apraxias may occur earlier. Ideomotor apraxia is characterized by inability to execute learned movements when prompted despite intact comprehension, sensation, motor strength and coordination. There may be difficulty in organizing and sequencing of movements involved in executing an action, e.g. pantomiming combing one’s hair or brushing teeth. Individuals with Alzheimer’s disease may
Impairment of executive function may result in cognitive, mood, behavioural and personality changes. The latter are discussed later as part of NPS. The cognitive symptoms of executive dysfunction are closely related to higher intellectual capacity and involve several aspects of higher intellectual function, including planning, sequencing, abstraction, set shifting and organizing. Features of executive dysfunction arise commonly early in the course of Alzheimer’s disease, and may be the primary reason why functioning becomes impaired and care is sought. There is often loss of generative thought, and inability to plan or organize several mental tasks simultaneously without the use of aids. Individuals who previously did not require daily to-do lists to successfully perform tasks may have progressive difficulty completing activities. It is important to note that there are age-associated declines in executive function; however, the mental flexibility that allows for the adaptive skills in the absence of dementia is often absent with Alzheimer’s disease. Ability to solve problems mentally is affected early. In addition, there may be impairment in symbolic and abstract thinking. Thoughts become more concrete and patients may have difficulty accurately interpreting proverbs. Poor response inhibition (e.g. impaired Stroop colour-word interference test), reduced ability to sustain and divide attention, and perseveration of sequential motor tasks can also be seen in Alzheimer’s disease at any stage of dementia or in the clinical prodrome to dementia.
NON-COGNITIVE NEUROPSYCHIATRIC SYMPTOMS ASSOCIATED WITH ALZHEIMER’S DISEASE Neuropsychiatric symptoms such as depression, apathy, agitation and delusions are nearly universal in dementia associated with Alzheimer’s disease. Over time, over 98% of individuals with Alzheimer’s disease experience at least one NPS disturbance during the course of their illness7 . In Alzheimer’s disease, the presentation, severity and frequency of these symptoms may fluctuate with progression of the illness. NPS can be classified based on individual symptoms or clusters of frequently co-occurring symptoms8 . The Neuropsychiatric Inventory (NPI) helps distinguish neuropsychiatric symptoms and signs into 12 domains: delusions, hallucinations, agitation, dysphoria, anxiety, apathy, irritability, euphoria, disinhibition, aberrant motor behaviour, night-time behaviour disturbances, and appetite and eating abnormalities9 (Table 41.2). NPS may be further differentiated based on a hierarchical approach into clusters of affective disturbance, psychotic disturbance, sleep disturbance, apathetic syndrome and executive dysfunction syndrome8 .
NPS with Prominent Affective Disturbance Symptoms of disturbed mood are the most common non-cognitive symptoms seen in Alzheimer’s disease. These include depression,
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PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRY Table 41.2 Other neuropsychiatric symptoms associated with Alzheimer’s dementia
Depressive symptoms may herald the onset of Alzheimer’s disease. Mood symptoms are more common in mild to moderate than in advanced dementia13 , although this apparent difference may be a result of difficulties evaluating the mental state of patients with advanced disease. Differentiating Alzheimer’s disease with depression from other forms of late life depression (e.g. major depressive disorder) may be challenging as the symptoms overlap. Apathy, anxiety, diminished motivation, sleep disturbance and appetite dysregulation are examples of overlapping symptoms. However, the sustained subjective dysphoria seen with major depressive disorder is not characteristic of depression in Alzheimer’s disease. Furthermore, unlike individuals with major depressive disorder, depressed patients with Alzheimer’s disease may not report hopelessness, worthlessness and suicidal thinking but rather endorse symptoms of irritability, anxiety, and diminished interest and motivation14 . Less commonly, elation and mood lability may present in Alzheimer’s disease. These mood changes are rarely sustained and are often attenuated by redirection. Delusions may occur in the context of either an affective disturbance or a psychotic disturbance. Delusions are rare in late-life depression but occur in over 30% of patients with dAD. Individuals with Alzheimer’s disease have diminished insight as the disease progresses; however, in the early stages they may become demoralized. Feelings of demoralization often resolve as they adjust to the disease or lose insight with illness progression. Appetite dysregulation affects an estimated 37.8% of patients with Alzheimer’s disease15 . These symptoms are more prominent with
Behavioural disturbance and personality changes (apathy, aggression, agitation, disinhibition and aberrant motor behaviour) Mood disturbance (depression, anxiety, irritability) Psychomotor abnormalities (sleep disturbance, appetite dysregulation) Perceptual disturbance (delusions, hallucinations, illusions)
anxiety, irritability, agitation and elation. Depression is the most common mood symptom with an estimated five-year cumulative prevalence of 77%, and an average point prevalence of 31%10 (Figures 41.1 and 41.2). Depressive symptoms which may also present in the context of a typical major depressive episode are often part of an atypical affective syndrome occurring in Alzheimer’s disease referred to as ‘depression of Alzheimer’s disease’ (dAD)11 or ‘affective disorder associated with Alzheimer’s disease’12 . Depression is often co-morbid with apathy. More than 40% of apathetic Alzheimer’s disease patients present with depression and 56.4% of those with depression also present with apathy13 . Other symptoms associated with depression in Alzheimer’s disease include impaired sleep, anhedonia, poor concentration, diminished energy and appetite disturbances.
35
30
25
20
15
10
5
14.1
19.9
31.4
y ilit tb ia Irr
tio bi in hi is D
20.3
Figure 41.1 Point prevalence of neuropsychiatric symptoms in a community-based US sample10
9.9
25
Ab e m be o rra ha tor nt vi or
n
y et
0.6
xi
19.2
An
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H al lu ci na tio n Ag Ag i gr tati es on si / on De Dy pre sp ss ho ion ria /
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0
9.3
DEGENERATIVE AND RELATED DISORDERS
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80
70
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40
30
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10
41
77
y ilit tb ia
D
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is
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Figure 41.2 Five-year period prevalence of neuropsychiatric symptoms in a community-based US sample10 severe Alzheimer’s disease. With progressive decline in independent function, individuals with Alzheimer’s disease often exhibit irregular nutritional intake. Behavioural disturbances including irritability, agitation and disinhibition may have a greater impact on eating patterns and the quality of nutritional intake than the level of cognitive impairment16 . Furthermore, there may be loss of appetite secondary to degeneration of hypothalamic regions associated with feeding and satiety. Nevertheless, without adequate supervision, those with advanced dementia have difficulty maintaining adequate daily nutritional support. Agitation and aggression in Alzheimer’s disease often manifest as emotional excitability, irritability, resistive behaviours, shouting or physical aggression. The estimated prevalence of agitation in Alzheimer’s disease is 20–25%10 . Agitated behaviours are not unique to Alzheimer’s disease and may also be a part of other latelife conditions, including primary psychotic, depressive or substance use disorders and unrecognized pain. Agitation may also be provoked by environmental stimuli. Agitation and aggressive behaviours occur more commonly with advanced Alzheimer’s disease. These behaviours are often seen in institutionalized Alzheimer’s disease patients and frequently precipitate institutionalization in those living in the community.
NPS with Prominent Psychotic Disturbance Delusions are a common neuropsychiatric symptom of Alzheimer’s disease with an estimated point prevalence of 23%10 and a prevalence range of 15–70%17 . The wide range in rates may be due to different
definitions of psychotic disturbance in Alzheimer’s disease18 . Delusions are unshakable false beliefs that are out of context with the individual’s social and cultural background, while hallucinations are false sensory perceptions that are not simply distortions or misinterpretations of actual stimuli. Delusions in Alzheimer’s disease have been associated with older age, male gender and a lower level of education19 . Delusions occur more frequently than hallucinations. The most common types are poorly developed paranoid delusions and misidentification syndromes. The features of paranoid delusions are often related to theft, believing personal objects have been misplaced or stolen, and infidelity. Some characteristic misidentification syndromes may include the belief that family members have been replaced by imposters (Capgras syndrome) or that a stranger (often a misidentified close family member) inhabits their homes (phantom boarder). They may also express the belief that they have been removed from their homes and placed in a foreign environment. There may be differences in cognitive deficits among patients with delusions or delusional misidentification. Patients with delusions often have significantly greater impairment of recent memory, while those with delusional misidentification may have greater impairment of receptive language function. Patients with delusions or delusional misidentification are more likely to have some insight into their psychotic symptoms, unlike those who experience visual hallucinations.20 . Delusions in Alzheimer’s disease may be associated with depression, aggression, agitation and anosognosia21 . Hallucinations are less common in Alzheimer’s disease than delusions, occurring in 13–16%17 of patients with Alzheimer’s disease at any point and may occur in up to 38% of these individuals over
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PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRY
a cumulative five-year period10 . Visual misperceptions are the predominant type of hallucinations in Alzheimer’s disease. However, if visual hallucinations occur early in the illness, dementia with Lewy bodies should be considered. There is an increase in cognitive impairment, functional decline, placement in institutionalized care and death associated with delusions and hallucinations22 . Delusions and hallucinations are seen more often in the moderate stages of Alzheimer’s disease and may persist and often recur over the course of the illness17 . Illusions are not often reported in Alzheimer’s disease and clinical evidence describing the features of illusions in this disease is limited. There is, however, some evidence that visual illusions, if present, may worsen with progression of Alzheimer’s disease23 .
Sleep Disturbance Sleep disturbance in dementia is associated with significant caregiver distress and may precipitate institutionalization of community dwelling individuals due to its burden on caregivers. Nocturnal insomnia presents a background for unsupervised and potentially unsafe behaviours such as wandering and pacing and may precipitate serious risk of harm to themselves and others. Environmental stimulation may also play a role in aetiology or propagation of sleep problems in dementia. An estimated 59.2% of those with advanced dementia have some evidence of sleep disturbance, with insomnia, excessive daytime somnolence and napping being most prevalent24 . Other symptoms include increased nocturnal awakenings and fragmented sleep. Insomnia is more common in patients with mild and moderate dementia while daytime sleepiness is more frequently associated with severe dementia24 . Objective assessments of sleep using wrist actigraphy and polysomnography indicate that individuals with Alzheimer’s disease in long-term care facilities may have increased total sleep time, increased sleep latency, increased REM sleep latency, less sleep efficiency, increased N1 non-REM sleep and decreased REM sleep25 .
Apathetic Syndrome Degeneration of the anterior cingulate gyrus and adjacent medial frontal lobe structures with disruption of the frontal and subcortical circuits is associated with apathy. Apathy is one of the most prevalent psychiatric phenomena in Alzheimer’s disease, affecting an estimated 75% of patients over the course of illness10 . Features of apathy commonly seen include both emotional and motor phenomena. There is decreased emotional range, reduced motivation, diminished volition to initiate new tasks and a decrease in goal-directed behaviour. Comparisons may be drawn with depressed individuals; however, unlike depression, persons with Alzheimer’s disease are not distressed or concerned with these symptoms. In rare cases, with severe dementia, there may be severe apathy in which individuals are awake but do not interact with the environment. They do not eat spontaneously unless fed, and do not attend to personal hygiene or maintain voluntary control over bowel and bladder functions.
Executive Dysfunction Syndrome Changes in behaviour, mood and personality are often associated with the late stages of Alzheimer’s disease. It is, however, not uncommon for these symptoms to present early in the clinical course. Other possible underlying causes, particularly the frontotemporal dementias, should be considered if behavioural and personality changes are
seen early in the disease. Disinhibition, environmental dependency and verbal or motor perseveration are less prevalent than most other neuropsychiatric symptoms and present more frequently in the late stages of the illness26 . Behavioural disinhibition and aberrant motor behaviours frequently precipitate placement into a nursing or assisted living home. Pacing and wandering are behaviours seen with increasing frequency with worsening dementia and may also precipitate placement into institutionalized care.
Other Clinical Features With progression of Alzheimer’s disease, there is an increasing risk of falls. This may be related to impairment in balance and gait, or poor coordination caused by the neurodegenerative process. Falls may also occur due to the effects of medications, orthostatic hypotension from cerebrovascular and cardiovascular dysfunction, and environmental hazards27 . Falls may be associated with scalp injury, subdural haematoma, traumatic brain injury and rarely skull fractures. In individuals with severe physical debility who have limited ambulation or are bed-bound, there is a significant elevated risk of decubitus ulcers. Alzheimer’s disease may also be a predisposing factor in delirium or infections, particularly of the respiratory and genitourinary tract.
REFERENCES 1. Hebert LE, Scherr PA, Bienias JL, Bennett DA, Evans DA. Alzheimer disease in the US population: prevalence estimates using the 2000 census. Arch Neurol 2003; 60(8): 1119–22. 2. Helzner EP, Scarmeas N, Cosentino S et al. Survival in Alzheimer disease: a multiethnic, population-based study of incident cases. Neurology 2008; 71(19): 1489–95. 3. Kuller LH, Ives DG. Vital records and dementia. Neuroepidemiology 2008; 32(1): 70–71. 4. Trzepacz PT, Mulsant BH, Dew MA et al. Is delirium different when it occurs in dementia? A study using the delirium rating scale. J Neuropsychiatry Clin Neurosci 1998; 10(2): 199–204. 5. Patterson MB, Schnell AH, Martin RJ et al. Assessment of behavioral and affective symptoms in Alzheimer’s disease. J Geriatr Psychiatry Neurol 1990; 3(1): 21–30. 6. Adelman AM, Daly MP. Initial evaluation of the patient with suspected dementia. Am Fam Physician 2005; 71(9): 1745–50. 7. Treiber KA, Lyketsos CG, Corcoran C et al. Vascular factors and risk for neuropsychiatric symptoms in Alzheimer’s disease: the Cache County Study. Int Psychogeriatr 2008; 20(3): 538–53. 8. Lyketsos CG. Neuropsychiatric symptoms (behavioral and psychological symptoms of dementia) and the development of dementia treatments. Int Psychogeriatr 2007; 19(3): 409–20. 9. Cummings JL. The Neuropsychiatric Inventory: assessing psychopathology in dementia patients. Neurology 1997; 48(5 suppl 6): S10–16. 10. Steinberg M, Shao H, Zandi P et al. Point and 5-year period prevalence of neuropsychiatric symptoms in dementia: the Cache County Study. Int J Geriatr Psychiatry 2008; 23(2): 170–77. 11. Olin JT, Schneider LS, Katz IR et al. Provisional diagnostic criteria for depression of Alzheimer disease. Am J Geriatr Psychiatry 2002; 10 (2): 125–8. 12. Lyketsos CG, Sheppard JM, Steinberg M et al. Neuropsychiatric disturbance in Alzheimer’s disease clusters into three groups:
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the Cache County study. Int J Geriatr Psychiatry 2001; 16(11): 1043–53. Lyketsos CG, Steinberg M, Tschanz JT et al. Mental and behavioral disturbances in dementia: findings from the Cache County Study on memory in aging. Am J Psychiatry 2000; 157(5): 708–14. Rosenberg PB, Onyike CU, Katz IR et al. Clinical application of operationalized criteria for ‘Depression of Alzheimer’s Disease’. Int J Geriatr Psychiatry 2005; 20(2): 119–27. Fernandez-Martinez M, Castro J, Molano A et al. Prevalence of neuropsychiatric symptoms in Alzheimer’s disease and vascular dementia. Curr Alzheimer Res 2008; 5(1): 61–9. Greenwood CE, Tam C, Chan M et al. Behavioral disturbances, not cognitive deterioration, are associated with altered food selection in seniors with Alzheimer’s disease. J Gerontol A Biol Sci Med Sci 2005; 60(4): 499–505. Bassiony MM, Lyketsos CG. Delusions and hallucinations in Alzheimer’s disease: review of the brain decade. Psychosomatics 2003; 44(5): 388–401. Leroi I, Voulgari A, Breitner JC, Lyketsos CG. The epidemiology of psychosis in dementia. Am J Geriatr Psychiatry 2003; 11(1): 83–91. Bassiony MM, Warren A, Rosenblatt A et al. The relationship between delusions and depression in Alzheimer’s disease. Int J Geriatr Psychiatry 2002; 17(6): 549–56.
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20. Ballard CG, Bannister CL, Patel A et al. Classification of psychotic symptoms in dementia sufferers. Acta Psychiatr Scand 1995; 92(1): 63–8. 21. Mizrahi R, Starkstein SE, Jorge R, Robinson RG. Phenomenology and clinical correlates of delusions in Alzheimer disease. Am J Geriatr Psychiatry 2006; 14(7): 573–81. 22. Scarmeas N, Brandt J, Albert M et al. Delusions and hallucinations are associated with worse outcome in Alzheimer disease. Arch Neurol 2005; 62(10): 1601–8. 23. Stavitsky K, Brickman AM, Scarmeas N et al. The progression of cognition, psychiatric symptoms, and functional abilities in dementia with Lewy bodies and Alzheimer disease. Arch Neurol 2006; 63(10): 1450–56. 24. Rao V, Spiro J, Samus QM et al. Insomnia and daytime sleepiness in people with dementia residing in assisted living: findings from the Maryland Assisted Living Study. Int J Geriatr Psychiatry 2008; 23(2): 199–206. 25. Martin JL, Ancoli-Israel S. Sleep disturbances in long-term care. Clin Geriatr Med 2008; 24(1): 39–50, vi. 26. Lyketsos CG, Rosenblatt A, Rabins P. Forgotten frontal lobe syndrome or ‘executive dysfunction syndrome’. Psychosomatics 2004; 45(3): 247–55. 27. Shaw FE. Falls in cognitive impairment and dementia. Clin Geriatr Med 2002; 18(2): 159–73.
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Neuropsychological Assessment of Dementia and Alzheimer’s Disease David Aaron Maroof and Cynthia A. Munro Department of Psychiatry and Behavioral Sciences, The Johns Hopkins University School of Medicine, Baltimore, USA
INTRODUCTION Clinical neuropsychology can be conceptualized as both the study of affective, behavioural and cognitive manifestations of brain function and the application of assessment procedures in quantifying these interrelated processes to inform decisions regarding the causes for dysfunction. The term neuropsychology has also been described as a ‘merger between experimental psychology and neurological sciences for studying relationships between the brain and behavior’1 (p. 139). Assessment procedures used by neuropsychologists are tasks that tap various domains of cognition, including, but not limited to, aspects of attention, processing speed, language, visuospatial skills, memory and executive functioning, as well as those assessing mood and aspects of personality. Responses to these tasks provide scores that are used to quantify an individual’s functioning in these domains. While we cannot physically observe cognition, we can infer its integrity with the use of standardized psychometric tests. Quantification of an individual’s optimal cognitive ability, considering his or her emotional status and personality characteristics and then determining whether one’s optimal cognitive ability represents disease, is the cornerstone of the neuropsychological assessment of dementia. In so doing, we improve diagnostic accuracy of dementia above routine clinical evaluation2 . How we accomplish this is the focus of this chapter. We have divided this chapter into five sections. First, we will provide a brief introduction to the field of neuropsychology. Second, we will discuss the role of the clinical neuropsychologist in the assessment of dementia. Third, we provide an overview of the basic patterns of cognitive test performance in dementia. Fourth, we discuss some common misconceptions about the practice of neuropsychology. Finally, we present some of the current trends in the neuropsychological assessment of dementia.
INTRODUCTION TO NEUROPSYCHOLOGY Neuropsychology is an amalgam of many disciplines, influenced by neuroanatomy, neurophysiology, neurochemistry, neuropharmacology, psychology and neurology3 , as well as philosophy, physiology and anatomy4 . Psychometric theory and application, as they relate to appropriate use of data analyses in test construction and the development of normative data, are the very linchpins of neuropsychological
assessment and substantiate the theoretical and conceptual networks of the discipline. The nexus between current neuropsychological theory and practice harks back to ancient philosophical thought3 . Ideas such as aestheticism (e.g., is a theory appealing?), rationalism and empiricism still fuel the practice of clinical neuropsychology5 . Glozman6 discusses the influence of Russian contributions dating back to the late 18th century from psychiatrists and neurologists and attributed many changes in neuropsychological practice – including combining both quantitative and qualitative approaches, expansion to include social and personality variables and increasing nosological patient groups – to this influence. A main theme that Glozman6 noted was ‘. . .not so much diagnostic but prognostic. . .neuropsychological assessment should rather emphasize the subject’s strengths which are important. . .and predict his/her ultimate integration into society’ (p. 177). The need for a systematic, valid and reliable method of measuring the manifestations of brain function emerged. Test construction thus came on the heels of conceptual and theoretical models of brain function and organization. Delineating the inception and progression of various neuropsychological tasks is beyond the scope of this chapter. However, we have selected to discuss one very commonly used method for assessing executive functioning to exemplify the manner in which some of our tests have been developed. Executive functioning is a cognitive process involving one’s ability to adapt and respond effectively to environmental demands, novel situations and ultimately deduce efficient and effective ways for completing them. Several ‘tributaries’ of executive functioning have been promulgated, including sequencing behaviours, abstraction, organization and planning. Eling and colleagues7 report on the influence of Narziss Ach who designed a paradigm for observing concept formation in the early 20th century. Nonsense words (on cards) were attached on various geometric figures of different shapes and sizes and once these cards were removed, the individual was required to deduce how the words related to the features of the objects. The quintessential element of this task is that one must discover the sorting principle. Goldstein and Scheerer1 underscored the abstract elements of this task, in which one must be able to abstract from a concrete object, while maintaining insight into other potential ‘choices’. The Wisconsin Card Sorting Test (WCST)8 was developed on the basis of these principles. Brenda Milner9 ultimately demonstrated that lesions in the
Principles and Practice of Geriatric Psychiatry, 3rd edn. Edited by Mohammed T. Abou-Saleh, Cornelius Katona and Anand Kumar 2011 John Wiley & Sons, Ltd
DEGENERATIVE AND RELATED DISORDERS dorsolateral prefrontal cortex resulted in shifting problems (i.e., perseverating) and subsequent research has repeatedly confirmed that damage to the frontal cortex is associated with poor performance on this task10 . Integrity of the perforant pathway (the principal source of input to the hippocampal formation) is essential for normal hippocampal function. In Alzheimer’s disease, it is the pathological changes in this pathway that preclude its normal operation of acquisition of contextual knowledge, presumably due to a disconnection among the hippocampal formation and input from sensory-specific and multi-modal association cortices11 . However, as the neuropathology spreads beyond the medial temporal lobe structures to the association cortices of the frontal, temporal and parietal lobes, higher order cognitive deficits result12 . Regarding cognitive assessment in Alzheimer’s disease, it is the juxtaposition of the neuropathological changes along the disease trajectory with administration of specific tests chosen to assess the associated cognitive deficits that is the cornerstone of clinical neuropsychology. The application of statistical methodology provides the intellectual spadework for clinical practice, as the interpretation of test performance requires the understanding of statistical principles underlying test construction and interpretation.
THE ROLE OF THE CLINICAL NEUROPSYCHOLOGIST The advent of neuroimaging in the 1970s changed the clinical neuropsychologist’s role from that of lesion detection to one of description of the cognitive sequelae of disease13 and/or diagnosis of disease for which imaging is uninformative. In general, there is a chasm between knowledge gleaned from neuroimaging and information gathered through neuropsychological examination. Imaging tells us what (e.g. cerebrovascular accident), where (e.g. anterior cerebral artery) and how (e.g. ruptured aneurysm), whereas neuropsychological examination tells us the consequences, including how much (degree of deficit) and in what way (memory, language, etc.) functioning has been affected. Neuropsychological assessment in dementia depends on the context of the referral question. In some cases, the neuropsychologist’s role is to determine whether cognitive impairment exists and if so, to assist with the differential diagnosis of its cause. In other cases, diagnosis of the disease causing the dementia has been established and the neuropsychologist is asked to determine areas of cognitive strength and weakness, to assist with the development of compensatory strategies. Neuropsychological assessment is also used to track disease progression through repeated examinations, at times determining whether changes in medication are associated with changes in cognition. In still other cases, neuropsychological assessment provides objective data to assist in determining whether a patient is competent to make independent decisions regarding medical, financial or other matters. Recommendations regarding whether a patient should cease driving or working are also informed by neuropsychological assessment. Thus, the context of the referral, even within the narrow scope of dementia assessment, is important to the information that is provided by the neuropsychologist.
RECOGNIZING PATTERNS OF NEUROCOGNITIVE FUNCTIONING IN THE DEMENTIAS It is quite often the case that clinical neuropsychologists must disentangle ambiguous complaints of declines in cognitive function.
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Memory complaints, for example, often dissemble the extent and typology of cognitive deficits. What can present as a memory deficit may be related to the bigger picture of a breakdown in semantic knowledge (e.g. naming), or difficulties with executive function that can affect one’s ability to carry out a series of everyday tasks. The pattern of performance exhibited on a neuropsychological examination provides information with regard to these core and peripheral deficits and in conjunction with a comprehensive anamnesis, offers etiological significance. The cortical–subcortical distinction proffers a heuristically useful model for describing the pattern of neuropsychological performance in various patient groups, despite observations that this is an oversimplified dichotomy14,15 . This distinction was engendered by the observation of different clinical presentations in patients with cortical compared to subcortical disease16 . Although the prototypical cortical dementia is that caused by Alzheimer’s disease, other diseases, such as frontotemporal lobar degeneration and Creutzfeldt–Jakob disease, are also associated with cortical pathology. Far greater in number, diseases causing subcortical dementia comprise, among others, progressive supranuclear palsy, Parkinson’s disease and Huntington’s disease and are associated with pathological changes involving the thalamus, basal ganglia and related brain-stem nuclei. Cortical diseases typically develop similar cognitive footprints, including deficits in language, learning and praxis, whereas patients with subcortical dementia typically demonstrate impaired attention/concentration, processing speed and executive function, as well as apathy and depression. Although the cortical/subcortical dichotomy is simplistic and does not account for disorders with both cortical and subcortical features (e.g. cortical-basal degeneration17 ), this distinction remains useful in the differential diagnosis of dementia. In clinical practice, the neuropsychologist must make several determinations when the question of dementia is being considered. After the tests are administered and the scores are obtained, these scores are compared against a normative sample; that is, a sample of individuals, typically of the same age, but sometimes of the same race, sex and education as the patient. This comparison yields standardized scores (percentiles, z -scores or t -scores) for each raw score. Upon examination of these standardized scores, the neuropsychologist must consider several questions. First, is the examination normal or abnormal? Second, if it is abnormal, does the examination indicate the presence of a cognitive disorder or dementia? Third, is the pattern of cognitive test performance suggestive of cortical or subcortical involvement? Fourth, what disease is underlying the cognitive disorder? Abnormal scores on individual tests can be defined by several means. In some cases, a score that is obtained by fewer than a particular proportion (often 2%) of the normal population is considered to be abnormal. However, in a large battery of neuropsychological tests, obtaining several scores that are in this ‘impaired’ range is quite normal18 . In other instances, an abnormal score is one that is unexpected given a particular patient’s premorbid ability. That is, if a patient has limited education or sensory deficits that preclude his or her ability to perform some aspects of a task, then an abnormal score might not represent a decline from premorbid ability. Likewise, if a patient has superior premorbid intellectual functioning, a score in the borderline range on a memory test might be considered an abnormal score for that individual. A second determination is then made regarding whether the presence of one or more abnormal scores constitutes an abnormal exam. This inference requires one to incorporate other information, such as
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the patient’s or informant’s complaints and the overall pattern of test scores. As already mentioned, the presence of one or more abnormal scores often occurs across a battery of neuropsychological tests in normal healthy adults. Thus, the neuropsychologist must determine whether the pattern of abnormal scores is clinically meaningful. This determination is informed by the clinician’s knowledge of patterns of test scores that occur in conditions causing dementia. Incorporating measures of emotional functioning are also useful in informing the clinician’s determination of whether an abnormal examination is the product of disease or is psychogenic in nature. The practice of interpreting neuropsychological test results is therefore an integrative process, incorporating the patient’s history, complaints and test data. Results from neuroimaging and neurological examination, if available, are also considered.
MISCONCEPTIONS ABOUT THE NEUROPSYCHOLOGICAL ASSESSMENT OF DEMENTIA The assessment of patients with dementia is often multidisciplinary, involving neurologists, psychiatrists, neuroradiologists, geriatric practitioners and/or family practice physicians. Among non-neuropsychologists, several misconceptions regarding the practice of our discipline appear pervasive. We describe several of these misconceptions, as they can hinder one’s understanding of the information provided by the neuropsychologist.
Cutoff Scores Perhaps a result of epidemiological studies that use various scores – such as a Mini Mental State Examination Score of 24 or below – to exclude individuals who are likely to have cognitive difficulties, the notion that a particular score on a given test can be used to indicate dementia is a common misconception. Such scores, when used for research purposes, are often chosen because they are uncommon in healthy individuals. A score that is equal to or below the 2nd or 10th percentiles, that is, a score that represents poorer performance than what 98% or 90%, respectively, of individuals score, are common ‘cutoff’ scores for research. However, many factors render these cutoff scores inappropriate for use in clinical practice: premorbid ability, effort and number of tests administered all determine whether a particular score is abnormal. Thus, it is inappropriate to apply a cutoff score to an individual, or to use phrases such as ‘he scored below the cutoff for dementia’, as such scores differ, depending on the individual. For this reason, the use of norms is a cornerstone of the practice of neuropsychology. Such norms are crucial to answering the basic question, ‘is this test score normal or abnormal?’ Which demographic factors should be considered in the development of normative tables is a topic with particular currency in the field.
Singularity of Domains Assessed by Particular Tests Another misconception about the practice of neuropsychological assessment is that each test taps a singular ability that is subserved by a discrete brain structure. In practice, two patients might perform poorly on the same task, but for different reasons. For example, if a patient is unable to copy a complex figure, it might be due to poor visual perception, difficulty with constructional praxis or problems
with executive functioning. By administering a battery of tests that assesses these domains in various ways and examining the pattern of test performance, we can then determine which domains are impaired in each patient. It is important to recognize, therefore, that a particular test may require intact functioning in several cognitive domains. It follows that failure to perform a test does not necessarily imply impairment in a single domain. In addition to the fact that various cognitive processes can subserve performance on the same task, it is also the case that functional networks account for the existence of similar cognitive impairments among individuals with different sites of lesions19 . A common misconception is that executive functioning is determined by integrity of the frontal lobe. Whereas several executive tasks have been associated with frontal lobe activity20 and have been shown to be impaired in patients with frontal lobe lesions21 , executive dysfunction can occur in the context of abnormal functioning in other areas as well22 .
Association between Premorbid Ability and Cognitive Test Performance A third misconception is that individuals with superior premorbid ability should perform in the superior range on all cognitive measures. This logic often leads to the false conclusion that average test performance represents impairment in high-functioning individuals. However, when this notion is tested empirically, it is simply not the case. On the contrary, individuals of above-average intellectual functioning perform better than those with average intelligence on approximately one-third of measures in a test battery. Individuals with lower IQ scores do perform significantly worse, however, than individuals with average intelligence on most measures23 . Thus, whereas low scores would be expected for individuals with lower intelligence, higher scores on all measures should not be expected among individuals with higher levels of intellectual functioning. While it is possible that average performance across all tests in a domain may represent a decline from premorbid ability in an individual with complaints in that domain, we cannot know this. In such cases, it is important to consider other factors and perhaps even then, the only way we can know whether disease exists is to repeat the examination after some time (usually one year or so) to determine if there is decline in test performance that would suggest the presence of disease.
Time Course of Recovery from Cognitive Deficits in Depression Depressed individuals can demonstrate cognitive dysfunction in the absence of demonstrable neuropathology24 and these deficits appear to be more pronounced in depressed elderly compared to younger individuals with depression25,26 . The most consistently documented deficits among elderly patients with depression involve psychomotor speed, executive functioning and memory for newly learned information27,28 . Thus, the prototypical cognitive deficits resulting from depression resemble those seen in ‘subcortical’ dementia29 . A common misconception concerning the cognitive deficits associated with depression is that they resolve coincident with remission of low mood. Longitudinal studies have shown, however, that cognitive deficits remain during episodes of symptom reduction and even during remission30 . The more effort a task requires for success, the less well individuals with depression tend to perform on it31 . Indeed, some evidence suggests that the relationship between
DEGENERATIVE AND RELATED DISORDERS depressive symptoms and performance on many cognitive tests is largely mediated by impairments of effortful processing28,32 . In a study by Hammar and colleagues33 , depressed patients were impaired on cognitively demanding tasks (those requiring effortful processing) when symptomatic and their impairments persisted even after six months, despite significant improvement in symptoms of depression. Similarly, Nebes and colleagues24 found that depressed elderly patients whose mood symptoms responded to treatment with an antidepressant medication (paroxetine or nortriptyline) showed no greater improvement over baseline performance in any cognitive domain than untreated healthy control subjects on five follow-up examinations taking place over 12 weeks. These studies and others suggest that the cognitive impairment observed among depressed elderly patients may be an enduring feature34 . Nevertheless, longitudinal assessment of depressed patients can assist in the differential diagnosis between depression and dementia, based on whether there is progressive cognitive decline over time.
RECENT TRENDS IN THE NEUROPSYCHOLOGICAL ASSESSMENT OF DEMENTIA The evolving field of neuropsychology is witness to numerous developments in the field of dementia and its treatment. These developments have led to changes in the questions we are asked to address and the approaches we use to conduct our evaluations of patients with dementia.
Early Detection of Neurodegenerative Disorder It is the deliberate use of neuropsychological testing that parallels the course of neuropathology that informs our choice of tests. In so doing, the neuropsychologist makes inferences regarding whether a pattern of test results relates to a pathological process suggestive of a particular disease. However, very early in the course of disease, our tests are not as sensitive in detecting abnormality as they become later in the course of disease. The goal of detecting and distinguishing from among the potential incipient dementias has implications both for prognosis and in determining whether to start relevant diseasespecific treatments12 . This goal has increasing currency in light of recent studies suggesting that some factors, such as diet and exercise, may act as modifiers to the risk of developing dementia and progression of mild cognitive impairment to dementia35 . Thus, being able to detect the very subtle cognitive changes that are the earliest manifestation of disease has gained more interest in recent years and includes as an objective the detection of a transitional state between normal ageing and dementia. This transitional state has been given several appellations, the most common in the United States being mild cognitive impairment (MCI)36 . Attempts at identifying this state have included the refinement of diagnostic nomenclature and increased sensitivity of neurocognitive tests to detect abnormality. Because many of our tests do not have ‘ceiling’ effects – that is, even normal healthy individuals do not earn perfect scores on them – the tests themselves are sufficiently difficult for even those with subtle cognitive problems. The interest, therefore, is in improving the diagnostic sensitivity of these tests. One way to do this is by improving the similarity between the normative sample and the patient we are assessing. The use of demographically adjusted scores (discussed in the following sections) is one method of achieving this. Clinical neuropsychologists sometimes reach an impasse when faced with attempting to detect cognitive changes in the behavioural
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variant of frontotemporal dementia (FTD). Specifically, the initial symptoms generally include changes in personality and social interaction, as well as disinhibition37 . Torralva and colleagues38 demonstrated that while cognitive measures of memory, attention, visuospatial analysis, executive function and language did not significantly differ in patients diagnosed with the behavioural variant of FTD compared to normal healthy individuals, the authors’ executive and social cognition battery did distinguish the groups. It is commonly thought that traditional testing environments may fail to induce executive deficits because of the inherent structure provided by the examination process. As such, the development of assessment tools that elicit abnormal behaviour is a challenge for the field.
The Use of Demographically Adjusted Test Scores Over the past century, neuropsychologists have interpreted individual test scores by comparing an individual’s test scores to a normative sample. The field has seen recent controversy regarding the composition of the norms we use. Specifically, which demographic variables should be considered is a matter of debate. The reason we use a normative sample is to determine the degree of deviation from the average, healthy individual, presumably because the patient was premorbidly similar to the average, healthy individual. Typically we choose to compare our patient with a sample of comparable age, due to the influence of age on many of our tests. It is sometimes desirable, however, to compare our patient with an individual who is comparable also in education level, due to the effects of education on test performance. Other normative samples include race and sex as well. Brickman and colleagues39 point out that the value of neuropsychological assessment is contingent on the psychometric properties of the individual tests. If African Americans, for example, have been shown to perform on average lower than Caucasians, a test based on data from the latter group will cause an increase in false positives (i.e. diagnosing someone as impaired, when in fact he or she is performing within normal limits). Such comparisons allow us to determine how similar our patient is to healthy individuals of the same demographic. A similar approach involves the calculation of a predicted score based on a patient’s demographic information40,41 . Both methods take into account demographic variables in informing the decision about whether a particular score is normal or abnormal and improve the sensitivity of our measures in identifying cognitive impairment. Silverberg and Millis42 have shown that adjusting scores can actually decrease the usefulness of test performance for predicting functional outcomes, such as the ability to work. If, for example, a 90-year-old individual is normal compared to other nonagenarians with regard to psychomotor speed, we may interpret his score as normal. However, given that the typical 90-year-old individual is much slower than the typical middle-aged individual, we may interpret the elder’s score as rendering him unable to perform tasks that require fast processing speed (e.g. being an air-traffic controller). Thus, whether to use demographic adjustments depends upon the question we seek to answer.
CONCLUDING COMMENTS The field of neuropsychology, influenced by such disparate areas of study as philosophy, neuroanatomy and psychology, is heavily reliant on statistical methods to substantiate its theoretical and conceptual frameworks. Psychometric theory and application, as they relate to
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appropriate use of data analyses in test construction and the development of normative data, are the very linchpins of clinical practice. Neuropsychological assessment in patients with suspected dementia provides an important source of diagnostic information, resulting from the empirically based choice of test batteries and the use of statistical methods to interpret these batteries. Although the role of the clinical neuropsychologist has evolved and depends upon the context of the evaluation, the information provided through neuropsychological assessment remains valuable in the differential diagnosis of dementia and improves diagnostic accuracy above routine clinical examination. The cortical/subcortical distinction, despite its being an oversimplification, remains a useful reference in the decision tree for individual cases. Faulty assumptions about our field relating to how we define abnormality, what our tests measure and the nature of cognitive dysfunction in the presence of low mood, can lead to misunderstandings about what our clinical evaluations can offer. Current trends in the neuropsychological assessment of dementia include, as in other fields, detection of the very earliest manifestation of disease. Increasing the sensitivity of our tests with the use of increasingly sophisticated statistical methods has resulted from the goal of improving our ability to detect subtle cognitive problems. It is not only the application of knowledge of neuropathological changes and clinical presentation of the various diseases causing dementia that distinguishes neuropsychology as a discipline. It is also the dovetailing of sound clinical judgement with appropriate statistical methodology that is required for good clinical practice.
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11. Hyman BT, Van Hoesen GW, Kromer LJ, Damasio AR. Perforant pathway changes and the memory impairment of Alzheimer’s disease. Ann Neurol 1986; 20: 472–81. 12. Salmon DP, Bondi MW. Neuropsychological assessment of dementia. Annu Rev Psychol 2009; 60: 257–82. 13. Wood RI. The scientist-practitioner model: How do advances in clinical and cognitive neuroscience affect neuropsychology in the courtroom. J Head Trauma Rehab 2009; 24: 88–99. 14. Salmon DP, Filoteo JV. Neuropsychology of cortical versus subcortical dementia syndromes. Sem Neurology 2007; 27: 7–21. 15. Brandt J, Munro, CA. Memory disorders in subcortical dementia. In Baddeley AD, Kopelman MD, Wilson BA. The Essential Handbook of Memory Disorders for Clinicians. Hoboken: Wiley, 2004, 591–614. 16. Hodges, JR, Salmon DP, Butters, N. Differential impairment in semantic and episodic in Alzheimer’s and Huntington’s diseases. Brain 1990; 114: 1547–58. 17. Pillon B, Blin J, Vidailhet M, Deweer B, Sirigu A, Dubois B, Agid Y. The neuropsychological pattern of corticobasal degeneration: comparison with progressive supranuclear palsy and Alzheimer’s disease. Neurology 1995: 45; 1477–83. 18. Schretlen DJ, Munro CA, Anthony JC, Pearlson GD. Examining the range of normal intraindividual variability in neuropsychological test performance. J Int Neuropsych Soc 2003; 9: 864–70. 19. Arango-Lasprilla JC, Rogers H, Lengenfelder J, Deluca J, Moreno S, Lopear F. Cortical and subcortical diseases: do true neuropsychological differences exist? Arch Clin Neuropsychol 2006; 21: 29–40. 20. Cummings JL. Frontal-subcortical circuits and human behavior. Arch Neurol 1993; 50: 873–80. 21. Banich M. Executive function: the search for an integrated account. Curr Dir Psychol Sci 2009; 18: 89–94. 22. Huey ED, Goveia EN, Paviol S, Pardini M, Krueger F, Zamboni G et al. Executive dysfunction in frontotemporal dementia and corticobasal syndrome. Neurology 2009; 72: 453–9. 23. Diaz-Asper CM, Schretlen DJ, Pearlson GD. How well does IQ predict neuropsychological test performance in normal adults? J Int Neuropsych Soc 2004; 10: 81–90. 24. Nebes RD, Pollock BG, Houck PR, Butters MA, Mulsant BH, Zmuda MD, Reynolds III CF. Persistence of cognitive impairment in geriatric patients following antidepressant treatment: a randomized, double-blind clinical trial with nortriptyline and paroxetine. J Psychiat Res 2003; 37: 99–108. 25. Dotson VM, Resnick SM, Zonderman AB. Differential association of concurrent, baseline and average depressive symptoms with cognitive decline in older adults. Am J Geriat Psychiatry 2008; 16: 3–18. 26. Gualtieri CT & Johnson LG. Age-related cognitive decline in patients with mood disorders. Prog Neuro Psychoph 2008; 32: 962–7. 27. Butters MA, Bhalla RK, Mulsant BH, Mazumdar S, Houck PR, Begley A et al. Executive functioning, illness course and relapse/recurrence in continuation and maintenance treatment in late-life depression: is there a relationship? Am J Geriat Psychiatry 2004; 12: 387–94. 28. Nebes RD, Butters MA, Mulsant BH, Pollock BG, Zmuda MD, Houck PR et al. Decreased working memory and processing speed mediate cognitive impairment in geriatric depression. Psychol Med 2000; 30: 679–91. 29. Crowe SF, Hoogenraad K. Differentiation of dementia of the Alzheimer’s type from depression with cognitive impairment on
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43
Genetics of Alzheimer’s Disease Lynn M. Bekris1 , Chang-En Yu1,2 , Thomas D. Bird1,2 and Debby Tsuang1,2 1 Departments
of Medicine, Neurology and Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA 2 Geriatric Research, Education and Clinical Center and Mental Illness Research, Education and Clinical Center, University of Washington School of Medicine, Seattle, WA, USA
INTRODUCTION
Clinical Symptoms
Prevalence and Incidence
Both EOAD and LOAD present clinically as dementia that begins with a gradual decline of memory and then slowly increases in severity until the symptoms eventually become incapacitating. Other common symptoms are confusion, poor judgement, language disturbance, agitation, withdrawal and hallucinations. Rare symptoms include seizures, parkinsonism, increased muscle tone, myoclonus, incontinence and mutism. Death commonly occurs from general inanition, malnutrition and pneumonia3 . Treatment of AD with cholinesterase inhibitors and memantine may result in slowing of cognitive decline in mild to moderate dementia cases, but overall, most patients experience only clinically marginal improvement in measures of cognition and in global assessments of dementia10,11 .
Alzheimer’s disease (AD) is the most common irreversible, progressive brain disease. It is characterized by a gradual loss of memory and cognitive skills. AD accounts for over 50% of all dementia cases and it presently affects more than 24 million people worldwide. Moreover, over 5 million new cases of AD are reported each year and the incidence is likely to increase as a greater proportion of the population ages1 . AD prevalence and incidence strongly suggest that age is the most influential known risk factor. Indeed, AD prevalence increases significantly with age and AD incidence increases from 2.8 per 1000 person years for people between 65 and 69 years to 56.1 per 1000 person years for people who are older than 90 years2 . Approximately 10% of persons older than 70 years have significant memory loss and more than half of these individuals have probable AD. An estimated 25% to 45% of persons older than 85 years have dementia3 . The duration of disease is typically 8 to 10 years, with a range from 2 to 25 years after diagnosis. The disease is divided into two subtypes based on the age of onset: early-onset AD (EOAD) and late-onset AD (LOAD). EOAD accounts for approximately 1% to 6% of all cases and ranges roughly from 30 years to 60 or 65 years. On the other hand, LOAD, which is the most common form of AD, is defined as AD with an age at onset later than 60 or 65 years. Both EOAD and LOAD may occur in people with a positive family history of AD. Approximately 60% of EOAD cases have multiple cases of AD within their families and of these familial EOAD cases, 13% are inherited in an autosomal dominant manner with at least three generations affected4,5 . Earlyonset cases can also occur in families with late-onset disease3 . With the exception of a few autosomal dominant families that are singlegene disorders (see below), most AD cases appear to be a complex disorder that is likely to involve multiple susceptibility genes and environmental factors3,6 – 9 .
Clinical Diagnosis Currently, the diagnosis of AD is based on clinical history and neuropsychological tests. The Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV), criteria for diagnosing dementia requires the loss of two or more of the following: memory, language, calculation, orientation or judgement12 . The Mini-Mental State Examination (MMSE) helps to evaluate changes in a patient’s cognitive abilities. In addition, a diagnosis of probable AD necessitates the exclusion of other degenerative disorders associated with dementia, such as frontotemporal dementia (including frontotemporal dementia with parkinsonism-17 and Pick’s disease), Parkinson’s disease, diffuse Lewy body disease, Creutzfeldt–Jakob disease and cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL)13 . Discriminating AD from other forms of dementia is usually done through clinical history and neuroimaging3 . In addition, other possible causes of dementia need to be excluded, especially the treatable forms of cognitive impairment, such as impairment due to depression, chronic drug intoxication, chronic central nervous system infection, thyroid disease, vitamin deficiencies (e.g., B12 and thiamine),
Principles and Practice of Geriatric Psychiatry, 3rd edn. Edited by Mohammed T. Abou-Saleh, Cornelius Katona and Anand Kumar 2011 John Wiley & Sons, Ltd
DEGENERATIVE AND RELATED DISORDERS central nervous system angitis and normal-pressure hydrocephalus3 . Individuals who do not meet these criteria but have short-term memory loss, have only minimal impairment in other cognitive abilities and are not functionally impaired at work or at home are considered to have ‘mild cognitive impairment’14 .
Neuropathological Diagnosis A definitive diagnosis of AD requires a clinical assessment of probable AD, as well as postmortem confirmation, with the presence of two histopathological features: neurofibrillary tangles and amyloid plaques15 – 17 . Before autopsy confirmation, expert clinicians correctly diagnose AD between 80% to 90% of the time18 . Even though plaques and tangles are often found in cognitively normal agematched controls, the density and the distribution of these attributes are more severe in patients with AD, according to standardized histological assessments15 . Amyloid plaques are extracellular with a cross-beta structure that is characteristic of dye-binding (neuritic amyloid plaques contain thioflavin S and Congo red-positive
A
B APP prior to secretase cleavage
APP
fibrillar deposits with both Aβ40 and Aβ42 present)19,20 . The major component of amyloid plaques is amyloid beta (Aβ), which can be stained and detected using Aβ antibodies21,22 . The most common form of Aβ in humans is 40–amino-acids long and is called Aβ40. A 42–amino-acid-long fragment, Aβ42, is less abundant than Aβ40 and differs only in that it has two additional amino-acid residues at the C-terminus. Aβ42 is associated with AD23 . Aβ is derived from the amyloid precursor protein (APP) by the action of two aspartyl proteases. First, α-secretase (non-neurotoxic ‘normal’ cleavage) or β-secretase (potential neurotoxic ‘abnormal’ cleavage) cleave APP (Figure 43.1) and second, γ -secretases cleave APP24 – 26 . Upon cleavage by α-secretase, APP releases a large soluble APP alpha fragment (sAPPα) and a membrane-bound C-terminal 83–amino-acid fragment (C83); whereas upon cleavage by β-secretase, APP releases a large soluble APP beta fragment (sAPPβ) and a membrane-bound C-terminal 99–amino-acid fragment (C99)27,28 . The C99 fragment is subsequently cleaved by γ -secretase to release Aβ and an APP intracellular domain (AICD)29,30 (Figure 43.1). Thus, depending on the point of cleavage
C APP subsequent to a-secretase cleavage
APP
sAPPa
239
D APP subsequent to b-secretase cleavage
APP
C99 subsequent to g-secretase cleavage
sAPPb
Ab
C99
b-secretase a-secretase
C99
C83 Extracellular
g-secretase
Cell Membrane AICD
Intracellular
Figure 43.1 APP cleavage. The APP protein can be cleaved by three different secretases; α, β or γ (panel A). Subsequent to ‘normal’ α-secretase cleavage, sAPPα is produced and released into the extracellular space and the C83 peptide remains in the cell membrane (panel B). Subsequent to β-secretase cleavage, sAPPβ is produced and released into the extracellular space and the C99 peptide remains in the cell membrane (panel C). Subsequent to β-secretase cleavage, the C99 peptide is ‘abnormally’ cleaved by γ -secretase to yield an Aβ peptide and the AICD peptide (panel D). Scale is approximate Source: Reproduced from Bekris, Yu, Bird & Tsuang (2010). The Genetics of Alzheimer’s and Parkinson’s Disease. In: A. Lajtha (Ed.), Handbook of Neurochemistry and Molecular Neurobiology, 3rd edn. Neurochemical Mechanisms in Disease, Vol. 36. New York: SpringerVerlag. With kind permission of Springer Science+Business Media
240
PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRY
by γ -secretase, two main forms of Aβ are produced, consisting of either 40 or 42–amino-acid residues (Aβ40 or Aβ42). The proportion of Aβ40 to Aβ42 that is formed is particularly important in AD because Aβ42 is far more prone to oligomerize and form fibrils than the more abundantly produced Aβ40 peptide. Indeed, although it appears that the production of Aβ isoforms is a normal process of unknown function, in a small number of individuals, an increased proportion of Aβ42 appears sufficient to cause EOAD16,31 . Neurons bearing neurofibrillary tangles are another frequent finding in AD brains32,33 and the temporal and spatial appearance of these tangles, which contain hyperphosphorylated tau, more closely reflects disease severity than does the presence of amyloid plaques34,35 . Tangles are formed by hyperphosphorylation of a microtubuleassociated protein known as tau, causing it to aggregate in an insoluble form. However, neurofibrillary tangles are also found in other disorders, such as frontotemporal dementia and progressive supranuclear palsy. Moreover, these tangles are not necessarily associated with the cognitive dysfunction and memory impairment that is typical of AD and mutations in the gene that encodes the tau protein (MAPT ), a main component of neurofibrillary tangles, has not been genetically linked to AD22 .
GENETICS OF ALZHEIMER’S DISEASE Introduction Overall, more than 90% of AD cases appear to be sporadic and to have a later age at onset of 60 to 65 years (LOAD)36 . Although twin studies support the existence of a genetic component in LOAD, no causative gene has been yet identified. Indeed, the only gene that has been consistently found to be associated with sporadic LOAD, across multiple genetic studies, is the apolipoprotein E (APOE ) gene37 – 41 (Table 43.1). However, many carriers of the APOE risk allele (ε4) live into their 90s, which suggests the existence of other LOAD genetic and/or environmental risk factors that have yet to be identified. To this end, several unreplicated genetic variants have been reported and these findings suggest that there may be five to seven major LOAD susceptibility genes3,42,43 . For a catalogue of candidate gene association studies, please refer to the AlzGene online database (www.alzforum.org/res/com/gen/alzgene/default.asp).
Genes Associated with Autosomal Dominant Alzheimer’s Disease
AD1: Amyloid precursor protein (APP) Inheritance and clinical features
In the 1980s, Kang and colleagues purified both plaque and vascular amyloid deposits and isolated their 40-residue constituent peptide (Aβ), which subsequently
led to the cloning of the APP type I integral membrane glycoprotein from which Aβ is proteolytically derived44 . The APP gene was then mapped to chromosome 21q, which accounted for the observation that Down syndrome patients (trisomy 21) develop amyloid deposits and the neuropathological features of AD when in their 40s22,45 – 47 . Since then, over 32 different APP missense mutations have been identified in 85 families. Interestingly, most of these mutations are located at the secretase cleavage sites or the APP transmembrane domain on exons 16 and 17 (Figure 43.2). Information regarding APP mutations are available in the NCBI database and the Alzheimer Disease Mutation Database (www.molgen.ua.ac.be/ADMutations)48 . Mutations within APP account for 10% to 15% of early-onset familial AD (EOFAD)3,49 – 51 , appear to be family specific and do not occur within the majority of sporadic AD cases. The majority of these EOFAD mutations are in or adjacent to the Aβ peptide sequence (Figure 43.2), the major component of amyloid plaques52,53 . Most cases containing APP mutations have an age of onset in the mid-40s and 50s54 .
Gene location and structure
Sequences encoding APP were first cloned by screening cDNA libraries44 . The initial full-length cDNA clone encoded a 695–amino-acid protein (APP695)40 and consisted of 18 exons. The APP gene, located on chromosome 21q21, is alternatively spliced into several products, named according to their length in amino-acids (i.e., APP695, APP714, APP751, APP770 and APP563) and expressed differentially by tissue type whereby the three isoforms that are most relevant to AD are restricted to the central nervous system (APP695) or expressed in both the peripheral and CNS tissues (APP751 and APP770)44,55 – 61 .
Gene function and expression
APP is a type-I integralmembrane protein44 that resembles a signal-transduction receptor. It is expressed in many tissues and concentrated in the synapses of neurons. Its primary function is not known, though it has been implicated in neural plasticity62 and as a regulator of synapse formation63 . APP is synthesized in the endoplasmic reticulum, post-transcriptionally modified in the golgi (N- and O-linked glycosylation, sulfation and phosphorylation) and transported to the cell surface via the secretory pathway. APP is also endocytosed from the cell surface and processed in the endosomal-lysosomal pathway64,65 . APP and its byproduct Aβ have been found to be translocated inside mitochondria and implicated in mitochondrial dysfunction66 – 68 . Proteolysis of APP by α-secretase or β-secretase leads to the secretion of sAPPα or sAPPβ. This proteolysis generates C-terminal fragments of 10 kDa and 12 kDa, respectively, which are inserted into the membrane. These fragments can be cut by γ -secretase to
Table 43.1 Alzheimer’s disease (AD) genes. AD genes are located on four different chromosomes and are associated with autosomal dominant or sporadic inheritance AD loci
Gene symbol
Gene name
Chromosome
Inheritance
AD1 AD2 AD3 AD4
APP APOE PSEN1 PSEN2
Amyloid Precursor Protein Apolipoprotein E Presenilin 1 Presenilin 2
21q21 19q13.32 14q24.2 1q42.13
Autosomal Dominant Sporadic Autosomal Dominant Autosomal Dominant
Source: Reproduced from Bekris, Yu, Bird & Tsuang (2010). The Genetics of Alzheimer’s and Parkinson’s Disease. In: A. Lajtha (Ed.), Handbook of Neurochemistry and Molecular Neurobiology, 3rd edn. Neurochemical Mechanisms in Disease, Vol. 36. New York: Springer-Verlag, Table 1. With kind permission of Springer Science+Business Media
V715M, V715A
770 aa
I716V, I716F, i716T L723P K724N
T714A, T714I
KM670/671NL D678N
341
Ab
Thr714
e as
e
se
cr
et
as
e
et
as
cr
et cr
se
se
a-
b-
TM
Lys687
Met671
KPI
g-
291
17
1 aa SP
V717F, V717G, V717I
241
E693G, E693del
DEGENERATIVE AND RELATED DISORDERS
Figure 43.2 AD1: APP structure and mutations. SP: Signal peptide. KPI: Kunitz protease inhibitor domain. Aβ: Amyloid beta. TM: Transmembrane domain. Scale is approximate Source: Reproduced from Bekris, Yu, Bird & Tsuang (2010). The Genetics of Alzheimer’s and Parkinson’s Disease. In: A. Lajtha (Ed.), Handbook of Neurochemistry and Molecular Neurobiology, 3rd edn. Neurochemical Mechanisms in Disease, Vol. 36. New York: SpringerVerlag. With kind permission of Springer Science+Business Media extracellularly release the Aβ peptide69 and intracellularly release a cytoplasmic fragment identified as AICD70 (Figure 43.1). The majority of EOFAD mutations alter this processing of APP in such a way that Aβ42 levels are changed relative to other Aβ isoform levels71,72 . The function of these APP proteolytic fragments is still unclear. The missense APP ‘Swedish’ mutations (APPSW, APPK670N, M671L) and the ‘London’ mutations (APPLON, APPV717I) are examples of APP mutations that lead to increased Aβ production and development of AD73,74 . Transgenic mouse models of such APP mutations (PDAPP, Tg2576, APP23, TgCRND8 and J20) have been developed75 . Each of these mouse models have different APP expression levels and different neurological abnormalities75,76 . For example, the Tg2576 mouse model that carries the ‘Swedish’ mutation has high APP levels, high Aβ levels and cognitive disturbances77 that are progressive and start as early as six months of age78 .
Genetic variation
APP transcripts have been identified in which exons 7, 8 and 15 are alternatively spliced. APP695 , the predominant isoform in neurons79 , contains exon 15 but excludes exons 7 and 8. The APP751 isoform and the APP770 isoform both encode Kunitztype protease inhibitor (KPI)-containing forms of APP 58 – 60,80, , are present in both peripheral tissue and neurons and contain exon 16 and 17 but exclude exons 7, 8 and 15. The gene region that encodes the portion of APP that is cleaved to produce the Aβ peptide is located
within exons 16 and 17 of the APP770 splice variant81 (Figure 43.2). Other splice variants have been observed that are missing exon 15 in various combinations with exons 7 and 8; these splice variants are referred to as L-APPs80,82 . A number of studies have indicated that alternative splicing of exons 7 and 8 is modulated in brain during ageing and possibly during AD82 – 87 . Even though the function of APP and its various splice variants is unknown, differential expression of these splice variants between tissues may imply functional differences. It is important to note that while most of the described splice variants contain Aβ-encoding sequences, two additional rare transcripts, APP365 and APP563 do not, implicating additional functionally important variability in APP isoform function55,88 . The first described and best characterized APP mutation (V717I) is located within the transmembrane domain near the γ -secretase cleavage site73 (Figure 43.2). Other substitutions have since been identified at this site and several groups have reported the V717I mutation in families who are unrelated to the initial London family. Many other APP mutations have since been identified, especially near the γ -secretase cleavage site, and the bulk of these mutations have been associated with modulation of Aβ levels. For example, a C-terminal L723P mutation was identified in an Australian family; this mutation is reported to generate an increase of Aβ42 peptide levels in CHO cells89 . The majority of EOFAD mutations alter processing of APP in such a way that the relative level of Aβ42 is
242
PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRY
increased by increasing Aβ42, decreasing Aβ40 peptide levels or increasing Aβ42 while decreasing Aβ40 peptide levels71,72 .
AD3: Presenilin 1 (PSEN1) Inheritance and clinical features
Linkage studies established the presence of an AD3 locus on chromosome 1490 , and positional cloning led to the identification of mutations in the presenilin-1 (PSEN1 ) gene, which encodes a polytopic membrane protein91 . Presenilins are major components of the atypical aspartyl protease complexes that are responsible for the γ -secretase cleavage of APP 92,93 . Mutations in PSEN1 are the most common cause of EOFAD. Indeed, PSEN1 missense mutations account for 18% to 50% of autosomal dominant EOFAD cases94 . Over 176 different PSEN1 mutations have been identified in 390 families. PSEN1 mutations appear to increase the ratio of Aβ42 to Aβ40 and thereby result in a change in function that leads to reduced γ -secretase activity95 . It has been suggested that deposition of Aβ42 may be an early preclinical event in PSEN1 mutation carriers96 . Defects in PSEN1 cause the most severe forms of AD, with complete penetrance and an onset occurring as early as 30 years of age. However, there is a wide variability in age of onset as other PSEN1 -associated AD cases have a mean age of onset greater than 58 years. PSEN1 -associated AD is an autosomal dominant neurodegenerative disorder characterized by progressive dementia and parkinsonism, notch signalling modulation and Aβ intracellular domain generation16,97 . There is also considerable phenotypic variability in PSEN1 -associated AD cases, including some patients who develop spastic paraparesis and other atypical AD symptoms. Some of these variable clinical phenotypes have been associated with specific mutations. Neuropathological studies often confirm the clinical diagnosis of AD with measurement of amyloid plaque and Braak stage (as described above) as well as other neurodegenerative changes in other brain areas according to the presence of specific PSEN1 mutations98,99 . For example, researchers found that the clinical and neuropathological features of a Greek family with a PSEN1 mutation (N135S) included memory loss when the family members were in their 30s, as well as variable limb spasticity and seizures. Upon neuropathological examination of these family members, the diagnosis of AD was confirmed and there was also histological evidence of corticospinal tract degeneration99 . Moreover, a PSEN1 mutation (I143M) that lies in a cluster in the second transmembrane domain of the protein has been described in an African family with an age at onset in the early 50s and a short duration of illness of six to seven years. These family members were diagnosed upon autopsy with severe AD pathology characterized by neuronal loss, abundant Aβ neuritic plaques and neurofibrillary tangles and degeneration extending into the brain stem100 .
Gene location and structure
PSEN1 is located on chromosome 14q24.2. It consists of 12 exons that encode a 467–amino-acid protein that is predicted to traverse the membrane 6 to 10 times; the amino and carboxyl termini are both oriented toward the cytoplasm101 .
Gene function and expression
PSEN1 is a polytopic membrane protein that forms the catalytic core of the γ -secretase complex92,102 . Gamma-secretase is an integral membrane protein typically found at the cell surface, but it may also be found in the golgi, endoplasmic reticulum and mitochondria92,103 .
PSEN1 , nicastrin (Nct), anterior pharynx defective 1 (Aph-1) and presenilin enhancer 2 (PSENEN) are required for the stability and activity of the γ -secretase complex104 – 108 . This complex cleaves many type-I transmembrane proteins, including APP and Notch92,109 , two proteins in the hydrophobic environment of the phospholipid bilayer of the membrane107 . PSEN1 knockout (KO) mice are not viable110 but a conditional PSEN1 KO mouse model, where the loss of the gene is limited to the postnatal forebrain, found that KO mice exhibited mild cognitive impairments in long-term spatial reference memory and retention111 . These findings suggest that presenilins play a role in cognitive memory. Moreover, knockin mice with missense mutations of the endogenous murine PSEN1 have high Aβ42 levels and perform poorly on the object recognition test112,113 . Double PSEN1 /APP transgenics have been developed and these transgenic suggest that PSEN1, APP and mutations within these genes play a role in the production of Aβ 76,114 .
Genetic variation
To date, there have been 176 PSEN1 mutations reported (Figure 43.3). A comprehensive list of PSEN1 mutations is available through the NCBI database (www.molgen.ua.ac.be/ ADmutations). The majority of these mutations are missense mutations. These missense mutations cause amino-acid substitutions throughout the PSEN1 protein and appear to result in a relative increase in the ratio of Aβ42 to Aβ40 peptides; this increase seems to occur through increased Aβ42 production, decreased Aβ40 production, or alternatively, a combination of increased Aβ42 production and decreased Aβ40 production71 . For example, individuals that carry the PSEN1 L166P mutation can have an age at onset in adolescence, and in vitro studies indicate that this mutation induces exceptionally high levels of Aβ42 production as well as impaired notch intracellular domain production and notch signalling98 .
AD4: Presenilin 2 (PSEN2) Inheritance and clinical features A candidate gene for the chromosome 1 AD4 locus was identified in 1995 in a Volga German AD kindred with a high homology to the AD3 locus (PSEN1 ); this gene was later named presenilin 2 (PSEN2 )51,115,116 . In contrast to the mutations in the PSEN1 gene, missense mutations in the PSEN2 gene are a rare cause of EOFAD, at least in Caucasian populations. The clinical features of PSEN2 -affected families appear to differ from the clinical features of PSEN1 -affected families in that the age of onset in these family members is generally older (45–88 years) than for some family members with PSEN1 mutations (25–65 years). Furthermore, the age of onset is highly variable among PSEN2 -affected members of the same family, whereas in families with PSEN1 mutations, the age of onset is generally quite similar among affected family members, and it is even similar among people from different families with the same mutation5,51,91,116 . Missense mutations in the PSEN2 gene may be of lower penetrance than in the PSEN1 gene and therefore may be subject to the modifying action of other genes or environmental influences51,117 . Gene location and structure The PSEN2 gene is located on chromosome 1 (1q42.13) and was identified by sequence homology and then cloned115,116 . PSEN2 has 12 exons and is organized into 10 translated exons that encode a 448–amino-acid peptide. The PSEN2 protein is predicted to consist of nine transmembrane domains
243
C410Y
453 467
431
TM9
A431E, A431V
426
406
394
TM8
L392V
TM7
E280A
TM6
367
268
TM5
A260V
241 245
215 222
TM4
M233T, M233L, M233V, M233I
TM3
193
183
161
M139T, M139I, M139K L153V I143F, I143N, I143M M146I
TM2
Y115C, Y115D, Y115H
A79V
TM1
154
132
100
1 82
T116N, T116I P117S, P117L
DEGENERATIVE AND RELATED DISORDERS
Figure 43.3 AD3: PSEN1 structure and mutations. Thus far, there have been at least 123 mutations in the PSEN1 gene described, of which a few are shown. For a more complete list of PSEN1 mutations see www.molgen.ua.ac.be/ADMutations. TM: Transmembrane domains. Scale is approximate Source: Reproduced from Bekris, Yu, Bird & Tsuang (2010). The Genetics of Alzheimer’s and Parkinson’s Disease. In: A. Lajtha (Ed.), Handbook of Neurochemistry and Molecular Neurobiology, 3rd edn. Neurochemical Mechanisms in Disease, Vol. 36. New York: SpringerVerlag. With kind permission of Springer Science+Business Media and a large loop structure between the sixth and seventh domains (Figure 43.4). PSEN2 also displays tissue-specific alternative splicing115,116,118 – 120 .
Gene function and expression Like PSEN1, PSEN2 has been described as a component of the atypical aspartyl protease called γ -secretase, which is responsible for the cleavage of Aβ 92,93 . PSEN2 is expressed in a variety of tissues, including the brain, where it is expressed primarily in neurons121 . PSEN2 -associated mutations have been reported to increase the ratio of Aβ42 to Aβ40 (Aβ42/Aβ40) in mice and humans71,95 , indicating that presenilins might modify the way in which γ -secretase cuts APP. APP processing at the γ -secretase site has been reported to be differentially affected by specific presenilin mutations. For example, PSEN1 -L166P mutations cause a reduction in Aβ production whereas PSEN1 -G384A mutations significantly increase Aβ42. In contrast, PSEN 2 appears to be a less efficient producer of Aβ than PSEN 123 . The functions and biological importance of presenilin
splice variants are poorly understood, but it appears that differential expression of presenilin isoforms may lead to differential regulation of the proteolytic processing of the APP protein. For example, aberrant PSEN2 transcripts lacking exon 5 appear to increase the rate of production of Aβ peptide122 , whereas naturally occurring isoforms without exons 3 and 4 and/or without exon 8 do not affect production of Aβ 123 .
Genetic variation
Mutations in PSEN2 are a much rarer cause of familial AD than are PSEN1 mutations; PSEN2 mutations have been described in six families, including the Volga-German kindred where a founder effect has been demonstrated48,51,115,116 , whereas PSEN1 mutations have been found in 390 families. To date as many as 14 PSEN2 mutations have been identified. One of the first mutations to be identified was a point mutation located within the second transmembrane domain that resulted in the substitution of an isoleucine for an asparagine at residues 141 (N141l)115 . Most recently, a V393M mutation
TM6
TM8
434 448
407 412
385
304
274
287 TM7
TM9
D439A
TM5
V393M
TM4
247 252
223 230
188 204
167
TM3
N141I
TM2
T122P, T122R
R71W
160
138
106
88
1
TM1
T430M
M174V
PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRY V148I
244
Figure 43.4 AD4: PSEN2 structure and mutations. Thus far, there have been at least 16 mutations in the PSEN2 gene described, of which a few are shown. For a more complete list of PSEN2 mutations see www.molgen.ua.ac.be/ADMutations. TM: Transmembrane domains. The V393M novel mutation was most recently found in one case124 . Scale is approximate Source: Reproduced from Bekris, Yu, Bird & Tsuang (2010). The Genetics of Alzheimer’s and Parkinson’s Disease. In: A. Lajtha (Ed.), Handbook of Neurochemistry and Molecular Neurobiology, 3rd edn. Neurochemical Mechanisms in Disease, Vol. 36. New York: SpringerVerlag. With kind permission of Springer Science+Business Media located within the seventh transmembrane domain has been described124 (Figure 43.4). A comprehensive list of PSEN2 mutations is available through the NCBI database (www.molgen.ua.ac.be/ ADmutations).
Genes Associated with Risk in Sporadic Alzheimer’s Disease
AD2: APOE Inheritance and clinical features
The APOE gene has been associated with both familial late-onset and sporadic late-onset AD in numerous studies of multiple ethnic groups. The APOE ε4 genotype is associated with higher risk of AD125 , earlier age of onset of both AD126 and Down syndrome (where there is an additional copy of chromosome 21 carrying the APP gene)127 and a worse outcome after head trauma128 and stroke, both in humans129 and in transgenic mice expressing human apoE4130 . The frequency of the APOE ε4 allele varies between ethnic groups, but regardless of ethnic group, APOE ε4-carriers are more frequently found in controls, and APOE ε4+ carriers are more frequently found in AD patients39 – 41,131 – 140 .
Gene location and structure
The APOE gene is located on chromosome 19q13.2 and consists of four exons that encode a 299–amino-acid protein. The APOE gene is in a cluster with other apolipoprotein genes: APOC1, APOC2 and APOC4 . The APOE ε4 loci are located within exon 4 of the gene. The three APOE ε4 alleles (ε2, ε3 and ε4) are defined by two single nucleotide polymorphisms, rs429358 and rs7412, which encode three protein
isoforms (E2, E3 and E4). The most frequent apoE isoform is apoE3, which contains cysteine and arginine at amino-acid positions 112 and 158. In contrast, these positions contain only cysteine residues in apoE2 and only arginine residues in apoE4 (Figure 43.5). The cysteine-arginine substitution affects the three-dimensional structure and the lipid-binding properties between isoforms. In apoE4, the amino-acid substitution results in the formation of a salt bridge between an arginine in position 61 and a glutamic acid in 255; whereas apoE3 and apoE2 bind preferentially to high-density lipoproteins (HDLs), this changed structure causes the apoE4 isoform to bind preferentially to very low-density lipoproteins (VLDLs)141 .
Gene function and expression
The mechanisms that govern apoE toxicity in brain tissue are not fully understood. Some proposed mechanisms include isoform-specific toxicity, APOE ε4-mediated amyloid aggregation and APOE ε4-mediated tau hyperphosphorylation142 . The APOE polymorphism is unique to humans and has been proposed to have evolved as a result of adaptive changes to diet143,144 . It is known that apoE plays an important role in the distribution and metabolism of cholesterol and triglycerides within many organs and cell types in the human body141 . Individuals carrying APOE ε4 have higher total and LDL cholesterol145 . Moreover, in vitro neurons have a cholesterol uptake that is lower when lipid are bound to apoE4 compared to apoE2 and apoE3146 , and apoE4 appears to be less efficient than the other isoforms in promoting cholesterol efflux from both neurons and astrocytes147 . As the major apolipoprotein of the chylomicron in the brain, apoE binds to a specific receptor and works through receptor-mediated
rs7412
rs429358
DEGENERATIVE AND RELATED DISORDERS
245
SNP Position (Amino-Acid) rs429358 (C112R)
rs7412 (R158C)
ε2
TGC (C)
TGC (C)
ε3
TGC (C)
CGC (R)
ε4
CGC (R)
CGC (R)
R
299 aa
150 R158C
C112R 130
1 aa
Allele
(a)
(b)
Figure 43.5 AD2: APOE structure and single nucleotide polymorphisms (SNPs). The general protein structure of apoE is shown . The two SNPs and corresponding protein locations are shown (rs429358 and rs7412; C112R and R158C) (panel A). R: Receptor binding domain. Scale is approximate. The APOE ε2, ε3, ε4 haplotype is shown in panel B Source: Reproduced from Bekris, Yu, Bird & Tsuang (2010). The Genetics of Alzheimer’s and Parkinson’s Disease. In: A. Lajtha (Ed.), Handbook of Neurochemistry and Molecular Neurobiology, 3rd edn. Neurochemical Mechanisms in Disease, Vol. 36. New York: SpringerVerlag. With kind permission of Springer Science+Business Media endocytosis to rapidly remove chylomicron and VLDL remnants from circulation; this process is essential for the normal catabolism of triglyceride-rich lipoprotein constituents148 . In the brain, lipidated apoE binds aggregated Aβ in an apoE isoform-specific manner, with apoE4 being much more effective than the apoE3 isoform. Researchers have also proposed that the more efficient binding process of apoE4 enhances the deposition of the Aβ peptide149 . Brain cells from APOE knockout (APOE -/-) mice are more sensitive to excitotoxic and age-related synaptic loss150 , and Aβ-induced synaptosomal dysfunction in these mice is also enhanced compared to control animals151 . When human apoE isoforms (apoE3 and apoE4) are expressed in APOE -/- mice, the expression of apoE3, but not apoE4, is protective against age-related neurodegeneration150 and Aβ toxicity151 . In addition, astrocytes from APOE -/- mice that express human apoE3 release more cholesterol than those expressing apoE4; this suggests that apoE isoforms may modulate the amount of lipid available for neurons. Other studies report apoE-specific effects on Aβ removal from the extracellular space whereby the apoE3 isoform has a higher Aβ-binding capacity than apoE4152,153 . Animal and in vitro models show that, in the brain, astrocytes and microglia are the main producers of secreted apoE154,155 . ApoE secretion in human primary astrocytes can be reduced by a combination of cytokines156 ; whereas under stress conditions, neurons appear to be the main producers of apoE157,158 . In a rodent model, moderate injury has been shown to induce enhancement of apoE levels in clusters of CA1 and CA3 pyramidal neurons159 and in another rodent model, apoE levels have been shown to increase in response to peripheral nerve injury161 . In addition, individuals carrying APOE ε4 have higher amyloid and tangle pathology160 and an increase in mitochondrial damage162 compared to those carrying other APOE polymorphisms. The gene dose of APOE ε4 is a major risk factor for AD, with many studies reporting an association between gene dose, age at onset163 and cognitive decline164 . After age 65, the risk of AD among individuals with a family member with AD increases depending on the number of ε4 alleles present in the affected individual. Risks to family members with the APOE 2/2 and 2/3 genotypes are nearly identical at all ages to risks for family
Genetic variation
members with the APOE 3/3 genotype. Among family members with APOE 3/3, the lifetime risk for AD by age 90 can be as much as three times greater than the expected risk found in APOE ε4 carriers, suggesting that factors other than APOE contribute to AD risk. In addition, a 44% risk of AD by age 93 among family members of APOE 4/4 carriers indicates that as many as 50% of people having at least one ε4 allele do not develop AD. There also appears to be a gender modification effect because the risk to male family members with APOE 3/4 is similar to that for the APOE 3/3 carriers but is significantly less than the risk for the APOE 4/4 carriers, whereas among female family members, the risk for the APOE 3/4 carriers is nearly twice that for the APOE 3/3 carriers131,133 – 140 .
SUMMARY AD is characterized by an irreversible, progressive loss of memory and cognitive skills that can occur in rare familial cases as early as the third decade. Currently, there is no cure for AD, and treatments only manage to slow down the progression of AD progression in some patients10,11 . The early-onset familial forms of AD have an autosomal dominant inheritance linked to three genes: APP, PSEN1 and PSEN2 , whereas the most common sporadic form of AD, which occurs after the age of 60, has thus far been consistently, across numerous studies, associated with only one gene, the APOE gene. The mechanistic contribution of these genes in AD pathogenesis has been studied extensively, but the specific biology involved in the progression of AD remains unclear, suggesting that AD is a genetic and environmentally complex disease.
GENETIC TESTING AND COUNSELLING APOE ε4 is most highly associated with AD for individuals with a family history of dementia and this association is highest for individuals that carry two APOE ε4 alleles (ε4/ε4 genotypes). The ε4/ε4 genotype is uncommon and although the ethnicity of the population may alter the expected prevalence, the genotype occurs in about 1% of normal Caucasian controls. In contrast, the ε4/ε4 genotype
246
PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRY
occurs in nearly 19% of familial LOAD populations. APOE ε4associated risk is also found in African Americans and Caribbean Hispanics165,166 . Women with an APOE ε4/ε4 genotype have a 45% probability of developing AD by age 73 years167 , whereas men have a 25% risk of developing AD by that age168 . AD risk is also lower for individuals with only one APOE ε4 allele (by age 87) or no APOE ε4 allele (by age 95)168 . Approximately 42% of persons with LOAD do not have an APOE ε4 allele169 . Thus, the absence of the APOE ε4 allele does not rule out a LOAD diagnosis. First-degree relatives of a person with LOAD have a cumulative lifetime risk of approximately 20% to 25%, whereas the risk in the general population is 10.4%134,170 . It is still not known whether the age of onset of a LOAD patient changes the risk to first-degree relatives of LOAD patients. But the number of additional affected family members most likely increases the risk to close relatives171 . Given the low predictive value of the APOE ε4 allele, the general consensus is that APOE genetic testing has limited value in asymptomatic persons for predicting AD risk172,173 . Family history may therefore be a better predictor of LOAD risk171 . In contrast, EOFAD, with an age at onset before 60 to 65 years old, has an autosomal dominant mode of inheritance in which 20% to 70% of cases are estimated to have a PSEN1 mutation, 10% to 15% of cases are estimated to have an APP mutation and PSEN2 mutations are rare172,174 . Indeed, approximately 60% of patients with EOAD have another known affected family member. The remaining 40% of EOAD patients may lack a family history because of an early death of a parent, failure to recognize the disorder in family members, or, very rarely, a de novo mutation5 . If an EOAD patient’s parent has a mutant allele, then the risk to the patient’s sibling of inheriting the mutant allele is 50%. The child of an EOAD patient who carries a mutation (APP, PSEN1 , or PSEN2 ) has a 50% chance of transmitting the mutant allele to each of their children. Testing of asymptomatic adults who are at risk for EOAD caused by mutations in the PSEN1 , PSEN2 , or APP genes is available clinically. However, genetic testing results for at-risk asymptomatic adults can only be interpreted after the disease-causing mutation has first been identified in the affected family member. It should be emphasized that testing of asymptomatic at-risk individuals with non specific or equivocal symptoms is predictive not diagnostic. In addition, obtaining results from genetic testing can affect an individual’s personal relationships as well as their emotional well-being and it may even cause depression. The principal arguments against testing asymptomatic individuals during childhood are that the testing then removes their choice to know or not know this information, it raises the possibility of stigmatization within the family and in other social settings and it could have serious educational and career implications. Thus, the general consensus is that individuals who are at risk for adult-onset disorders should not be tested during childhood. Prenatal genetic testing for mutations in the PSEN1 gene is possible if the PSEN1 allele has been identified in an affected family member first. Preimplantation genetic diagnosis is also available for families that have a disease-causing mutation. However, parental requests for prenatal or preimplantation genetic testing of adult-onset diseases is rare3 .
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44
Mouse Models of Alzheimer’s Disease Esther Oh, Constantine Lyketsos and Philip Wong Johns Hopkins School of Medicine and Johns Hopkins Bayview, Baltimore, USA
Advances in the development of animal models of neurodegenerative diseases have accelerated translation of basic science research into application in humans. While many different animal models are currently being studied in research settings, this chapter will focus on transgenic (tg) mouse models of Alzheimer’s disease (AD). There are two main types of tg mouse models of AD: models of amyloidosis and/or of tauopathy. These two types represent the two major pathological changes seen in AD, amyloid plaques and neurofibrillary tangles (NFTs). More recently, a model combining both features has been developed, allowing researchers to study their interaction. Important variations are conditional tg mouse models of AD in which the expression of transgenes can be manipulated – induced or inhibited – by external controls, and models in which normal (or endogenous) genes of interest have been deleted from a selected locus (‘knock-outs’). The following sections describe representative models in each category, and discuss advantages and disadvantages of each model. Finally, clinical implications of findings from animal studies are discussed.
TRANSGENIC MOUSE MODELS OF AMYLOID-BETA AMYLOIDOSIS Although human familial AD (FAD) comprises a small portion of AD cases, the identification of genetic mutations associated with FAD in genes coding for the amyloid precursor protein (APP) or presenilin 1 and 2 (PS1, PS2) led to development of the earliest tg mouse models. APP is cleaved by proteolytic enzymes, β- and γ -secretases, to form amyloid-beta (Aβ) 40 and 42, the main components of the amyloid plaques1 . Mutations in the APP gene create excess Aβ deposition by enhancing β-secretase cleavage of APP or by altering the pattern of γ -secretase cleavage of APP. This results in a higher Aβ42 to Aβ40 ratio, which in turn enhances Aβ fibrillogenesis. One of the first strategies to create AD-like pathology in mice was to develop tg mouse models that over-express human APP with FAD mutations. While over-expression of APP is not a general feature of AD, this approach led to tg mice with significant Aβ production and deposition over their lifetime. One such tg mouse model, known as PDAPP, uses a platelet-derived growth factor β (PDGF β) promoter to enhance in mice the expression of human APP with V717F mutation2 . Another early tg mouse model, Tg2576, uses the hamster prion protein promoter (PrP) to enhance the expression of human APP with a double Swedish mutation (K670N/M671L)3 . Both
models have been extensively studied as models of Aβ amyloidosis (Table 44.1). Another approach to developing tg AD mouse models involved the insertion of human presenilin genes with mutations known to cause AD into the mouse genome. Presenilins are part of the γ -secretase complex, which is involved in the cleavage of APP along with β-secretase. However, mouse models with PS1 mutations alone do not develop amyloid pathology4,5 . When both APP and PS1 mutations are expressed together in tg mice, such as in APPswe/PS1dE9 (Table 44.1)6 , the PS1 mutation increases the ratio of Aβ42 to Aβ40, resulting in more Aβ deposition due to the higher fibrillogenic nature of Aβ427 . Many of the tg mouse models of amyloidosis also develop other pathologies seen in the human disease such as neuritic plaques, gliosis or synaptic loss, allowing for observation of the effect of amyloid on neuronal pathologies. Significantly, monoaminergic neurodegeneration, a feature of the human disease, occurs in at least one mouse model8 . These models have been very useful to the identification of mechanism-based therapeutics, specifically, anti-amyloid therapies. However, a major limitation is that the amyloidosis models do not develop NFTs, one of the hallmark neuropathological changes seen in AD.
TRANSGENIC MOUSE MODELS OF TAUOPATHY The amyloid cascade hypothesis1 proposes that Aβ is an early upstream agent that is followed by excess phosphorylation of tau, an intracellular, microtubule-associated protein. Hyperphosphorylation of tau is thought to lead to the formation of paired helical filaments (PHF), which progress to become NFTs in the neuronal cell body. However, as mentioned above, tg mouse models of amyloidosis do not form NFTs. One reason may be differences in tau isoforms across humans and mice. Six human isoforms of tau exist, each derived from alternative splicing in the brain of the same gene. There are only three isoforms in mice, which may result in a lower propensity for hyperphosphorylation9. There is currently no known tau mutation in AD. However, independent of amyloid plaques, tau inclusions are found in other neurogenerative diseases such as progressive supranuclear palsy (PSP), corticobasal degeneration (CBD), Pick’s disease (PiD) and frontotemporal dementia (FTD). Therefore, tg mouse models of tauopathy have been created using human mutations in the tau
Principles and Practice of Geriatric Psychiatry, 3rd edn. Edited by Mohammed T. Abou-Saleh, Cornelius Katona and Anand Kumar 2011 John Wiley & Sons, Ltd
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Table 44.1 Examples of mouse models of Alzheimer’s disease Model PDAPP mice (line
109)2
APPswe (Tg2576)3
Double transgenic mice: Mo/Hu APPswe/PS1dE96
Conditional transgenic mice: rTg451014
Conditional transgenic mice: CaMKIIα-tTA × tet-APPswe/ind13
Triple transgenic mice: 3xTg-AD PS1, APPswe,tau11
Pros
Cons
Best use of model
Diffuse and neuritic plaques, synaptic loss, astrocytosis and microgliosis; significant impairment on a variety of different learning and memory tests Numerous Aβ plaques, oxidative lipid and glycoxidative damages; memory deficits seen in 9–10-month-old Tg mice Exhibit accelerated Aβ deposition despite relatively low level of APPswe over-expression; both transgenes are co-segregated; a similar model, line C3-3/S9, shows age-related deficits in behaviour31 These mice express repressible human FTDP-17 mutation P301L (4R0N taup301L ); progressive age-related NFT, neuronal loss and functional deficits are present; after the suppression of transgenic tau, memory function recovered and neuron numbers stabilized, but NFTs continued to accumulate These mice express repressible APP transgene with Swedish and Indiana mutations; they develop progressive amyloid plaques Amyloid plaque develops before tau pathology, and the regional distribution of amyloid and tau closely mimics human AD pathology; age-dependent decline in both spatial and contextual learning and memory
Some early age-independent memory and behavioural deficits; noncongenic strain background; no NFT or tau aggregates
Studies of passive and active anti-Aβ immunization; interactions between Aβ and apolipoproteins
No NTF or tau aggregates; early deficits in Morris water maze with visible platform; noncongenic strain background Noncongenic strain background; no NFT or tau aggregates
Studies of immunotherapeutic approaches; breeding with other AD models; use of NSAIDs and other treatments
No Aβ accumulation; gross forebrain atrophy, with preservation of hindbrain structures
Studies of reversibility of cognitive and pathological alterations
No NFT or tau aggregates; high expression lines are hyperactive
Studies of reversibility of pathological alterations
May be difficult to differentiate the effect of amyloid from tau
Studies of anti-Aβ immunization; understanding the relationship between amyloid and tau pathology; testing the amyloid cascade hypothesis
Studies of efficacy of different experimental treatments; breeding of these mice to other transgenic mice is efficient owing to co-segregation of the transgenes
Source: Adapted from Savonenko et al ., 2005
gene linked to familial frontotemporal dementia with Parkinsonism on chromosome 17 (FTDP-17). One such model, expressing the FTDP-17 mutation P301L, forms NFTs in diencephalon, brainstem, cerebellum and spinal cord. However, this model also has motor deficits due to spinal cord lesions such as fibrillary gliosis and axonal degeneration10 . More recently, models which reproduce both amyloid plaques and NFTs have been developed, the triple transgenic mice 3xTg-AD, which carry PS1 (M146V), APP (K670N/M671L) and tau (P301L) transgenes (Table 44.1)11 . Interestingly, even though both APP
and tau transgenes are expressed to similar levels in these mice, Aβ deposits emerge prior to tau pathology, consistent with the amyloid cascade hypothesis. Immunotherapy experiments involving direct injection of anti-Aβ antibodies into the hippocampus showed clearance of Aβ deposits followed by clearance of earlier (nonhyperphosphorylated) forms of tau. Aβ deposits re-emerged by 30 days post-injection, with tau pathology re-emerging at a later time point. Injection of anti-tau antibody had no observable effect on either Aβ or tau deposits. The data from these experiments further support the view that Aβ precedes tau pathology per the amyloid
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cascade hypothesis12 . These triple transgenic models are therefore quite useful for studying the role of tau protein in neurodegenerative diseases, and especially its interaction with amyloid pathology.
CONDITIONAL TRANSGENIC MOUSE MODELS Researchers have also developed variations of the above models in which the expression of APP, tau or both transgenes are temporally controlled. The approach used, commonly known as the ‘tet-off system,’ creates a tg model in which administration of a tetracycline analogue, such as doxycycline, turns off transcription of the transgene. Conditional tg models allow study of the effects of temporal variation (early vs. late, short vs. long) in the expression of the transgene. Such systems also model pharmaceutical interventions in which the expression of a transgene is suppressed, allowing assessment of potential treatment effect13 . They can also test the hypothesis of whether certain structural and biochemical changes are related to the expression of the transgene14 . A well-known conditional APP tg mouse model is CaMKIIαtTA × tet-APPswe/ind (Table 44.1). This model expresses amyloid plaques starting eight weeks of age, and amyloid deposition is severe by six months of age. APP expression is reduced by greater than 95% two weeks after initiation of doxycycline treatment. When doxycycline was given to examine the effects of Aβ suppression after the onset of deposition, further progression of Aβ deposition was halted, but there was limited to no clearance of previously deposited amyloid plaques even after six months of treatment. These results suggested that inhibition of Aβ production may halt further progression of the pathology, but may not clear the pre-existing amyloid plaques13 . A tg mouse model with conditional tau expression is rTg4510, in which mutant tau (P301L) expression is suppressed by administration of doxycycline (Table 44.1). This model has age-dependent formation of NFTs, loss of neurons, generalized forebrain atrophy and deficits in spatial memory. While formation of NFTs has been linked to subsequent neuronal loss and cognitive deficits, suppression of mutant tau gene starting at four months of age in these mice did not halt the accumulation of NFTs, even though there was a cessation in the loss of neurons and brain weight14 . In addition, there was improvement in memory function in these mice, despite progressive NFT accumulation. These findings imply that early memory deficits may be due to reversible neuronal dysfunction rather than irreversible development of NFTs or that there may be neuronal remodelling after the mutant tau gene suppression that allows recovery. Another implication from this study is that NFTs may not entirely account for the neuronal loss14 . Recently, the conditional triple tg mouse rTg3696AB that harbours two human Swedish APP mutations (K670N and M671L) at the β-secretase site, the London mutation (V717I) at the γ -secretase site (APPNLI ) and a tau mutation (P301L) has been created. This model shows Aβ deposits from 4 months of age, and NFTs from 11 months of age. Neuronal loss occurs at 13 months of age. Studies of the effects of transgene suppression, mimicking potential human therapeutic strategies, on pathologic and cognitive behavioural outcomes are in progress15 . This discussion illustrates the advantages of conditional tg mouse models, where temporal variations in the expression of transgenes as well as inhibition of select transgenes can demonstrate the potential role they play in the pathogenesis of neurodegeneration and cognitive behavioural symptoms.
KNOCK-OUT MOUSE MODELS Knock-out models are mice in which genes of interest have been selectively silenced. They are useful for determining the function of a specific protein or an enzyme, and for studying biological models of the enzyme inhibition. The APP gene is located on chromosome 21, and has many putative roles. Along with its homologues, the amyloid precursor-like proteins 1 and 2 (APLP1 and APLP 2), APP is thought to have roles in cell adhesion, motility, neuronal survival and neurite outgrowth. Interestingly, one of the APP knock-out mouse models (APP-/-) produces mice that are relatively healthy and fertile, with slightly lower body weight, decreased locomotion and increased reactive gliosis. The ability to maintain a relatively normal litter size was attributed to possible compensation for the loss of APP by its homologues16 . However, subsequent studies revealed behavioural deficit, defective long-term potentiation and GABA-mediated postsynaptic response in these mice17 . The microtubule-associated protein tau (MAPT) gene is located on chromosome 17q21. In normal human brain, tau is thought to be involved in stabilizing microtubles, which are located predominantly in axons. MAPT knock-out mice (Mapt -/-) do not have overt histological abnormalities. However, they exhibit muscle weakness on a rod walking (balance coordination) or a wire hanging (traction) test. They also demonstrate impaired contextual fear conditioning in foot shock experiments, which are thought to test amygdala and hippocampal functions. However, these impairments in Mapt -/- mice are thought to be due to hyperactivity of the mice rather than due to memory impairment since they exhibit hyperactivity in open fields but have intact spatial learning tasks18,19 . As with the APP knock-out models, the lack of significant pathologic deficits in tau knock-out models such as Mapt -/- may be due to compensation by other microtubule-associated proteins that may have overlapping function with MAPT protein19 . One example of a knock-out mouse model that demonstrates the function of an enzyme while serving as a biological model of enzyme inhibition is the BACE1 knock-out model (BACE1 -/-). This model demonstrates the role of the β-site amyloid precursor cleaving enzyme 1 (BACE1) in APP cleavage. Primary cortical cultures from the BACE1 -/- mouse embryos have undetectable levels of most Aβ40 and 42 species, demonstrating that amyloid is not produced, thus establishing BACE1 as the principal β-secretase in cortical neurons. More importantly, because the BACE1 -/- mouse model was viable, this model suggested that it may be possible to develop therapeutic β-secretase inhibitors to reduce Aβ deposition without mechanism-based adverse effects20 . While abnormal processing of APP and tau may result in neurotoxic substances, such as Aβ and NFTs, respectively, these knock-out mouse models demonstrate that APP and tau both play important roles in normal neuronal function. In addition, knock-out mouse models of enzymes such as BACE1 demonstrate the biological role of enzymes and the effects of targeting them as part of AD therapy.
DISCUSSION While Tg mouse models of amyloidosis do not fully reproduce the pathological changes seen in human AD, they have contributed significantly to our understanding of the pathophysiology of AD. Amyloid plaques, along with neurites, neurofibrillary tangles, loss of synapses and death of neurons, are the pathological hallmarks
DEGENERATIVE AND RELATED DISORDERS of AD21,22 . Most tg mouse models express either amyloid or tau pathology, although more recent models express both12,15 . Many models do not show loss of neurons23,24 , a critical feature of human AD. Several explanations have been proposed, including species variability in neuronal vulnerability, lack of key human-type inflammatory factors1 , species variability in amyloid burden, and differences in types of plaques that accumulate in different tg mouse models25 . Some tg mouse models also show age-independent behavioural deficits prior to Aβ deposition in the brain26 , which is different from human AD, in which amyloid deposition begins years before the clinical manifestations are evident. Model to model variability can also be attributed to the use of different promoters, resulting in different phenotypic expressions. Some tg mouse models have tissue-specific (e.g. brain)13 or more broadly expressed3 transgenes, depending on the promoter type. Differences in promoters can also result in differences in transgene expression levels, expression in irrelevant brain areas as well as expression at different times. Differences in background strains can also result in different phenotypic expressions even within the same tg mouse model19 . Despite limitations, tg mouse models are essential tools for investigating biological mechanisms and assessing potential treatments for AD. AD is characterized by gradual onset and progression of the brain disease over many years. One of the more difficult aspects of human AD research is the long duration of clinical trials, which can become prohibitive due to high patient attrition and costs. In addition, more researchers are focusing their efforts on the period preceding the AD diagnosis, preclinical and mild cognitive impairment (MCI) stages, extending the duration of the study. Tg mouse models have rapid breeding time and lower maintenance costs compared to primate models, allowing accelerated investigation of the mutated gene of interest. This results in shorter lead-time before the development of pathology (e.g. amyloid deposition in the brain) and the resultant behavioural changes. It also enables a researcher to design an intervention and observe pathological and behavioural changes within a short time frame. Many of these models have been used for evaluation of a treatment tool such as immunotherapy27 . They are also useful for environmental modifications such as enrichment28 and caloric restriction29 , and direct observation of their effects on behaviour as well as on neuropathology. Many of the tg mouse models develop impairments in learning and memory as assessed by well-established methods including the Morris water maze task9,30 . The difficulty of interpreting mouse behaviour partly arises from age-independent behaviours. These behaviours may be due to factors that are unrelated to Aβ toxicity such as transgene insertion and expression levels, strain background and promoter types9 . Differences in the timing of behavioural onset in relation to the Aβ deposition may also be due to the use of different tasks for behavioural testing as well as assessment of behaviour at different stages of learning9 . Recently, there have been efforts to elucidate potential soluble Aβ species that may contribute to the behavioural deficits, and that may, in part, explain the ageindependent behaviors26 . Some of the difficulties in human AD research arise from heterogeneity within the study population, which introduces confounders. Tg mouse models allow researchers to minimize the biological heterogeneity that may influence the outcome of interest by repeated backcrosses to an inbred breeding strain of mouse model up to at least tenth generation, creating a ‘congenic’ strain of the model. In conclusion, tg mouse models are useful for studying molecular
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mechanisms of a disease as well as for assessing therapeutic effect of drugs or environmental modifications, and continue to make significant contributions towards further understanding of AD.
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Physiological Neuroimaging in Ageing and Dementia: Metabolic and Molecular Scanning Markus Donix, Susan Y. Bookheimer and Gary W. Small David Geffen School of Medicine at UCLA, Los Angeles, USA
INTRODUCTION It is well recognized that in a process of cognitive decline leading to mild cognitive impairment (MCI) and dementia, detection of the underlying changes in brain structure and function will contribute to establishing an accurate diagnosis, with direct implications for pharmacological and non-pharmacological therapy planning. Since the first positron imaging device in 1950 or the first tomographs from single photon emission data in the 1960s, scientific advances in radionuclide development and detection research have led us to look beyond the brain’s regional blood flow (SPECT) or glucose metabolism (FDG-PET) into the patterns of amyloid plaque (PIB-PET) and tau tangle brain deposits (FDDNP-PET) or neuronal disintegrity (MPPFPET). With new methods entering clinical settings, we will need to balance our expectations for these new tools against availability and costs. Here we review the current state of metabolic and molecular imaging tools used in ageing and dementia, their utility, promise, as well as potential difficulties in bringing them into common practice. We will first review the basic techniques and then discuss their applications, including practical guidelines and results from the most recent studies reporting sensitivity, specificity and optimal uses.
SPECT Image Acquisition Single photon emission computed tomography (SPECT) measures the distribution of radioligands in the brain reflecting regional cerebral blood flow (rCBF), which itself is linked to brain metabolism. The tracer accumulates in proportion to the rate of delivery of blood to a distinct volume of brain tissue. Decades ago to patients this would have meant injection of 133 Xe or 85 Kr into the carotid artery. Today, within the commercial and experimental available radioligands technetium-99m labelled hexamethylpropyleneamine (99m Tc-HMPAO) and ethylcysteinate dimer (99m Tc-ECD) tracers are commonly used in brain SPECT imaging. After intravenous injection, these lipophilic compounds quickly cross the blood–brain barrier by diffusion and, due to slow brain clearance, the distribution of the radioligands then remains stable for hours. The underlying multicompartment clearance (‘microsphere’) model assumes that the tracer is freely diffusible, completely extracted to the brain and ‘fixed’ without redistribution. The emitted single
photons can be detected by a rotating gamma camera or ring-type imaging system. Spatial resolution is about 10 mm and could reach 5–6 mm using special-purpose detection systems that usually are not available for routine clinical scans. Spatial resolution in SPECT is only limited by technology (whereas PET resolution also depends on other factors1 ; see below) but today SPECT cannot compete with PET on image resolution and begins to lose its uniqueness within other factors. Cost-effectiveness still remains a controversy from a perspective that would take diagnostic accuracy and secondary costs into account; further, PET has become much more available, which also will make it less expensive. Resulting from physics-based differences, the possibility of simultaneous imaging of more than one radioagent is SPECT territory and a growing field of interest. Since all PET tracers share the same energy level, it would be much more difficult to perform simultaneous multiple tracer studies in PET. Signals would have to be separated based upon half-life or kinetics, which seems feasible in the future1,2 . Advanced SPECT technology is heavily reliant on detector improvements,
